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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