Online Application/Also Use for Application by Phone

Resident Application to Sober 4 Life Inc.:  CJO House

Personal Information:

Applicants Name:  Client first name  Client last name   

Desired move in date:  Client admit date

Estimated Length of Stay: Client estimated length of stay

Phone:  Client phone      Email Address: Client email

Date of birth:  Client birthdate     Age:  Text field    

Social Security Number: SSN

Gender:  Client gender      Pronoun: Client pronoun

Marital Status:  Client marital status

Race:  Client race   Ethnicity:  Client ethnicity

Veteran: Client veteran status


Hometown Address: Client Address


Was Client Referred?:  Client Referred By

Family Members/Emergency Contacts: Family Members 

Other Contacts: Contact

Prior Living Experiences: LivingArrangementHistory

Sober Living History: SoberLivingHistory

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


Applicant's Drug/Alcohol Use and Treatment:

Applicant's Drug of Choice:   Client substances of choice  

          1st 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 the name of the center, the start date, end date, approx discharge date: 

Treatment Center History:  TreatmentCenterHistory

        Case Manager:   Text field        Case Manager Contact Info: Paragraph

What brought the Applicant to that Treatment Center?  Paragraph

What was Applicant's longest clean time and when?  Paragraph 

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

Recovery History:  RecoveryHistory

Step: Client step

Sponsor: Client sponsor

Kinds of Meetings Attended: Client kinds of meetings attended

Health Problems:Client health problems

Allergies: Client allergies

Applicant's Current and Past Medications:

Diagnosis:  Client diagnosis

Medications: Medication

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

Provide any details if Applicant plans to continue maintenance meds:  Paragraph

Is Application on any other medications?  Radio buttons

       If yes, Applicant's provide all other Meds:



Education: EducationHistory

School: Client school

Therapist/Clinician: Therapist/Clinician 


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


Client's Insurance: Insurances


Applicant's Financial Information:

What Applicant's most recent or current occupation or job description: EmploymentHistory

Employment History: EmploymentHistory

What are Applicant's plans for employment while at our home:  EmploymentHistory    

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 the 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: