Application for Membership
Time 4 Sober Living House

 

To be accepted in a Time 4 Sober Living house an applicant must complete this application and be interviewed by
House Manager. Carefully read the application and honestly answer the questions. Living in a Time 4 Sober Living
house 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?

Radio buttons

Phone where you can be reached. Cell Client phone

Are you an Alcoholic?

Radio buttons

Date of last drink Date

Are you addicted to drugs?

Radio buttons

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

Radio buttons

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)

Checkboxes

Do you have a medical doctor?

Radio buttons

If yes:  doctor’s Name Text field   NumberText field

 

Please complete

Have you been to a treatment facility?

Radio buttons

If yes: treatment provider name Text field, phone number Text field, and
primary counselor Text field.

Do you take prescription drugs?

Radio buttons

If yes: List drugs and reason the drug has been prescribed:

Paragraph

Have you lived in a sober living house before?

Radio buttons

If yes: provide the name Text field and location Text field

If 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 or
friends. 

Contact 1

Name Contact 1 name   Address Text field
Relationship Contact 1 type   Telephone Contact 1 phone

Email: Contact 1 email

 

Contact 2

Name Contact 2 name   Address Text field
Relationship Contact 2 type   Telephone Contact 2 phone

Email: Contact 2 email

 

Contact 3

Name Contact 3 name   Address Text field
Relationship 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 want
to achieve recovery from alcoholism and/or drug addiction without relapse.

Signature

SIGNATURE

DATE Date

 

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