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)
Date of Birth Month
Present Address Street
Client Email:
Is this a treatment facility address?
Phone where you can be reached. Cell
Are you an Alcoholic?
Date of last drink
Are you addicted to drugs?
Date of last drug use?
List drugs you used addictively:
When did you attend your last AA or NA meeting?
How many AA/NA meetings do you now attend each week?
Are you currently employed
If yes: who is your employer?
What is your monthly income now? $
Your monthly income next month $
Marital status (Check One)
Do you have a medical doctor?
If yes: doctor’s Name
Have you been to a treatment facility?
If yes: treatment provider name
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
Relapse
Emergency Telephone Numbers. List family doctor, if you have one and two family member orfriends.
Contact 1
Name
Email:
Contact 2
Contact 3
Additional information
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.
SIGNATURE
DATE
For use by Time 4 Sober Living
Accepted
Move in date
House keys returned
Outstanding debt to house $
Time 4 Sober Living 919-576-0621 www.time4soberliving.com