Resident Application to Sober 4 Life Inc.: CJO House
Personal Information:
Applicants Name: Resident first name Resident last name
Desired move in date: Date
Phone: Resident phone Email Address: Resident email
Date of birth: Resident birthdate Age: Text field
Gender: Resident gender Marital Status: Checkboxes
Hometown Address: Resident mailing address
Prior Living Experiences:
Has Applicant ever lived in a sober house? Radio buttons
If yes, provide sober house names, dates and reason for leaving: Paragraph
Describe Applicant's most recent living location and situation: Paragraph
Applicants Drug/Alcohol Use and Treatment:
Applicant's Drug of Choice: Text field
Method: Text field Age First Used: Text field Date of last use: Text field
2nd Drug of Choice: Text field
Method: Text field Age First Used: Text field Date of last use: Text field
If Applicant is currently in a Treatment Center, provide name: Treatment center 1 name
Entry date: Treatment center 1 started Approx Discharge Date: Treatment center 1 ended
Case Manager: Text field Case Manager Contact Info: Text field
What brought Applicant to that Treatment Center? Paragraph
What was Applicant's longest clean time and when? Text field
Describe Applicant's Relapse History: Paragraph
Has Applicant ever overdosed? Radio buttons If yes, # of times: Text field Was Applicant hospitalized? Radio buttons
Provide any additional details regarding Applicant's overdose history: Paragraph
Provide and details regarding Applicant's participation in a recovery plan: Paragraph
Applicant's Current and Past Medications:
Has Applicant ever been on Maintenance Meds in the past? Radio buttons
If yes, describe what meds and when: Paragraph
Is Applicant currently on or plan to be on maintenance meds? Radio buttons If yes, provide names: Medication 1 name
Provide any details if Applicant plans to continue maintenance meds: Paragraph
Is Application on any other medications? Radio buttons
If yes, Applicant's provide other Meds:
Medication 2 name Medication 3 name Medication 4 name Medication 5 name
Applicant's Legal Matters:
Does Applicant have any outstanding Legal Matters? Radio buttons Describe: Paragraph
Does Applicant have a valid driver's license? Radio buttons If yes, provide State, License # and Expiration: Text field
Does Applicant plan on bringing a car? Radio buttons
Applicant's Financial Information:
What Applicant's most recent or current occupation or job description: Resident occupation
What are Applicant's plans for employment while at our home: Resident current employment
Applicant's Anticipated amount of monthly income: Text field
Provide any additional means of Applicant's financial support: Paragraph
Name of Person Completing this Application: Text field
If other than applicant, provide contact information: Text field
Signature: Signature
Today's Date: Date
By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.
For office use only:
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