First name Client first name
Last name Client last name
Previous Address Client Address
City Client City
State Client State
Zip Client Zip
Cell Client phone
Email address Client email
DOB Client birthdate
Race Client race
Marital Status Client marital status
Gender Client gender
Veteran Client veteran status
Emergency contact name: Contact 1 name
Phone Contact 1 phone
Relationship Text field
Do you have transportation arrangements necessary for appointments? (Explain)
Referral source (Be specific) Text field
What program are you applying for? Text field
Drug of choice: Client substances of choice
Have you ever been in a sober living program? Text field
If yes please tell us where, when and why you left. Text field
Facility/program Sober living 1 name
City Sober living 1 city
Reason for leaving Sober living 1 discharged
Length of stay Sober living 1 estimated length of stay
Please use this space to list any other sober living programs you have participated in.
Please list all arrests and charges you have in your past:
# of times incarcerated Text field
Length of time spent incarcerated: Text field
What facilities? Text field
What Counties were your charges Text field
Any pending charges?
Are you currently on probation?
PO name: Contact 1 name
Phone: Contact 1 phone
Do you agree to sign a release for us to contact?
List ALL substances you used addictively:
Do you consider yourself a drug addict?
What age did you start using alcohol or drugs? Text field
Please tell us about you treatment experiences...
Facility Name Treatment center 1 name
City Treatment center 1 city
Type Treatment center 1 type
Discharge Treatment center 1 reason for discharge
Please use this space for more informtion:
What is your sobriety date? Recovery history 1 sobriety date
How did you use your drug of choice? (IV, Snort, Oral) Text field
Are you currently employed?
If you are not employed or if you lose your employment you agree to obtain employment in 7 days?
Present marital status:
Client marital status
If single, do you have a significant other?
If yes, do you agree to delay that relationship for 6 months?
Spouse or Partner’s name: Contact 2 name
Phone Contact 2 phone
Type Contact 2 type
Years known: Text field
How do they support you in your recovery?
Children’s name Age Male/Female Lives with
Mental Health treatment
FacilityTreatment center 3 name
City Treatment center 3 city
Dischage Treatment center 3 reason for discharge
List all Diagnosis
Do you currently take any medications?
Are you med compliant?
Do you agree to keep ALL medication locked up?
List any trauma you have experienced:
What do you want to achieve while participating I our program?
What do you want to change in your life?
Why do you want to enter our program?
What positivity can you contribute to the residents of The Hope Society community?
Why are should we accept you into our program?
Use this space for additional information you feel The Hope Society’s treatment team should know about you.
Thank you for your application!