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
Emergency Telephone Numbers (List family doctor, if you have one, plus two family members or friends)
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
Date *
For assistance/additional information please contact our office at: Ph# (704) 264-1005.
Please allow 24 hours for review and response.