To be accepted in a Time 4 Sober Living house an applicant must complete this application and be interviewed byHouse Manager. Carefully read the application and honestly answer the questions. Living in a Time 4 Sober Livinghouse is special, you understand the value it can help you achieve comfortable sobriety without relapse.
Print Name (Last, First, Middle) Client first name Client middle name Client last name
Date of Birth Month Client birthdate
Present Address Street Client Address Client City Client State Client Zip
Client Email: Client email
Is this a treatment facility address?
Phone where you can be reached. Cell Client phone
Are you an Alcoholic?
Date of last drink Date
Are you addicted to drugs?
Date of last drug use?Date
List drugs you used addictively:
Client substances of choice
When did you attend your last AA or NA meeting? Date
How many AA/NA meetings do you now attend each week? Text field
Are you currently employed
If yes: who is your employer? Text field
What is your monthly income now? $Text field
Your monthly income next month $Text field
Marital status (Check One)
Do you have a medical doctor?
If yes: doctor’s Name Text field NumberText field
Have you been to a treatment facility?
If yes: treatment provider name Text field, phone number Text field, andprimary counselor Text field.
Do you take prescription drugs?
If yes: List drugs and reason the drug has been prescribed:
Have you lived in a sober living house before?
If yes: provide the name Text field and location Text fieldIf the answer to the above question was yes, provide the answer to the following:
Relapse Text field Voluntary Text field Other reason(s) Text field
Emergency Telephone Numbers. List family doctor, if you have one and two family member orfriends.
Name Contact 1 name Address Text fieldRelationship Contact 1 type Telephone Contact 1 phone
Email: Contact 1 email
Name Contact 2 name Address Text fieldRelationship Contact 2 type Telephone Contact 2 phone
Email: Contact 2 email
Name Contact 3 name Address Text fieldRelationship Contact 3 type Telephone Contact 3 phone
Email: Contact 3 email
Additional information Paragraph
I have read all the material on this application form. I have answered each question honestly and wantto achieve recovery from alcoholism and/or drug addiction without relapse.
For use by Time 4 Sober Living
Accepted Text field Not Accepted Text field
Move in date Date Move out date Date
House keys returned Text field
Outstanding debt to house $Text field Date repaid Date
Time 4 Sober Living 919-576-0621 www.time4soberliving.com