Email
*
Phone
*
(###)
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Date Of Birth
*
MM
DD
YYYY
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone
*
(###)
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Relationship To Emergency Contact
*
Who reffered you to our home?
*
Current Address
*
How Long Have You Lived At Current Address?
*
Why are you seeking a shared living arrangement?
*
Previous Landlord Name
*
First Name
Last Name
Previous Landlord Phone
*
(###)
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Current Employer Name
*
First Name
Last Name
Current Job Title
*
How long have you been employed here?
*
Employer Phone Number
*
(###)
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Monthly Income After Taxes
*
Do you have any other sources of income?
*
If yes , please explain
Previous Employer Name
*
First Name
Last Name
Previous employer contact number
*
(###)
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Previous job title
*
How long did you work here?
*
Do you smoke or vape?
*
Medical marijuana and other substances are prohibited in our sober living home. Are you willing to comply with this rule?
*
Are you currently sober?
*
If yes, How long have you been sober?
If no, are you willing to comply with our sober living rules?
*
Have you ever been in a sober living or shared living home before?
*
If yes, please provide details
Do you have any criminal history we should be aware of?
*
If yes, please explain
Are you comfortable cleaning up after yourself daily and participating in shared chores?
*
How do you feel about staying in a shared space with individuals of different backgrounds and personalities?
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Describe how you handle conflicts or disagreements with others in a shared environment.
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What are your personal growth goals while staying here?
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What is your current method of transportation?
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Do you have any family or friends who support your transition?
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If yes, Please provide their details and contact information
*
If you could no longer afford to stay with us, what would your plan be?
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Initial below if you agree -I understand that this is a sober living home, and I am required to follow all rules regarding sobriety
*
Initial below if you agree - I will clean up after myself and contribute to maintaining a clean and safe living environment
*
Initial below if you agree - I agree to treat all guest anf staff with respect and understand that disruptive behavior will not be tolerated.
*
Initial below if you agree - I will comply with all house rules, including curfews, guest policies, and chore assignments
*
Initial below if you agree - I understand that failure to comply with the house rules may result in my immediate removal from the home
*
Name of Reference #1
*
First Name
Last Name
Phone Number to Reference #1
*
(###)
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Relationship to reference #1
*
Name of reference #2
*
First Name
Last Name
Phone number to reference #2
*
(###)
###
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Relationship to reference #2
*
