Date of Birth *
Present Address *
Zip Code *
Check if treatment facility
Phone (home) *
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)
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
For assistance/additional information please contact our office at: Ph# (704) 264-1005.
Please allow 24 hours for review and response.
P.O.Box 35272 Charlotte, NC 28235-5272