Recovery House Application

Full Name*
First Last
Date*
Date Format: MM slash DD slash YYYY
Date Of Birth*
dd/mm/yyyy
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number*
Email*
Emergency Contact*
Name, Phone Number, & Relation
Current Treatment Center
Treatment Center Phone Number
Primary Counselor
Length of Program
Discharge Date
Date Format: MM slash DD slash YYYY
Past Treatment Programs
City/State Counselor Name Entry/Exit Date
Have you ever lived in a sober house?*
- Yes
- No
If yes, when and where?
Substance Use*
Drug Length of Abuse Time Since Last Use
Which recovery program are you currently working, or interested in? (i.e. A.A., N.A., Smart Recovery, etc.)*
What meetings do you attend?*
Do you have a sponsor?*
What is your source of income?*
Monthly Income*
Pending Legal Matters (please explain)
Any felony convictions? If “yes”, please explain*
Are you required to register as a sex offender?*
Have you been convicted of arson?*
Do you have any other mental health diagnosis?*
What is that diagnosis (and treatment)?
Have you ever experienced any suicidal ideations, attempts, or received in-patient treatment for self-harming behaviors? If yes, when?*
Current Medications and Dosage*
Why do you think you are a good fit for sober living?*
*
Signature Date

Recovery Housing Application Fields marked with an * are required

Author: Linda Impagliazzo

City/State	Counselor Name	Entry/Exit Date

Drug	Length of Abuse	Time Since Last Use