Fresh Start Sober Living Application

Name *

Date of Birth *

Present Address *

City *

State *

Zip Code *

Check if treatment facility

Phone (home) *

Phone (work)

Are you Alcoholic?Please SelectYesNo

Date of your last drink

Are you addicted to drugs? *Please SelectYesNo

Date of your last drug use

List drugs you have used addictively *

When did you attend your first AA or NA meeting? *

How many AA/NA meetings do you attend each week? *

Do you want to stop drinking alcohol and using addictive drugs? *Please SelectYesNo

Are you employed? *Please SelectYesNo

If "yes", who is your employer?

Are you receiving welfare or other non-job related income? *Please SelectYesNo

If “yes,” what?

If you do not have a job, will you get one? *Please SelectYesNo

If “yes,” what plans do you have?

What is your monthly income right now? $ *

What is your expected income next month? $ *

Do you possess an ID/Driver’s License (#/State)? *Please SelectYesNo

Do you possess an Social Security Card? *Please SelectYesNo

Do you possess a pair of WORK BOOTS? *Please SelectYesNo

Marital Status *Please SelectMarriedNever MarriedSeperatedDivorced

Do you have a doctor? *Please SelectYesNo

If “yes,” list the doctor’s name and phone

Have you ever been to a treatment facility for alcoholism and/or drug addiction? *Please SelectYesNo

If “yes,” list the treatment provider(s), phone number(s) and primary counselor(s), if any. List ALL occurrences.

Do you currently take prescription drugs? *Please SelectYesNo

If “yes,” list the medication, dosage, frequency and reason prescribed:

Are you currently on probation/parole/involved in a court case/in the legal system for any reason? *Please SelectYesNo

If “yes”, list reason/pending charges. Also, list all conviction(s), both felony and misdemeanor:

Date of requested move-in *

If not immediate, why?

Have you ever lived in Fresh Start Sober Living house before? *Please SelectYesNo

Have you ever lived in another halfway house? *Please SelectYesNo

If “yes” to either question, please list house name and location

I left the previous house for the following reason: *Please SelectRelapseVoluntarilyOther

If "other", please explain

Name *

Address *

Phone *

Name *

Address *

Phone *

Name *

Address *

Phone *

Use the following space for any additional relevant information you wish to provide:

I have read all of the material on this application form. I have also answered each question honestly and want to achieve recovery from alcoholism and/or drug addiction without relapse. *Please SelectYesNo

Name *

Date *