Recovery Residence Housing Application
Check the box below of the Organization you are applying to:
Checkboxes
Thank you for filling out our online application. Questions with a * must be completed in order to submit the application. All information is confidential. If you have not heard from us within 24 hours after submission, please call 612-991-1534 to speak with our Intake Coordinator. We look forward to welcoming you!
Our office mailing address is P.O. Box 135, Waconia, MN 55387
If mailing your deposit, please send money orders only with your name clearly written and the home you will be moving into.
If the blanks to be completed are yellow or you are unable to submit, the web browser you are using is outdated. Please update web browser or try a different web browser. The application can be completed with your cell phone.
General Questions
Today's Date:* Date
First Name:* Client first name Middle Name: Client middle name Last Name:* Client last name
Email: Client email Cell Phone Number: Client phone
Best number to contact you about your application: Text field
Gender (NSH/ASL is men's-only sober living. You must identify as male.): Client gender Birthdate:* Text field Age: Text field
If You Will Be Bringing A Vehicle To The Home, List Make And Model Here: Text field
Driver's License Number: Text field State DL Was Issued And Expiration Date: Text field
If you do not have a current driver's license, vehicle insurance, and current license tabs, do not bring your car or motorcycle.
Date You Would Like To Move In:* Text field
Have You Lived at a New Spirit Homes or American Sober Living Before? If So, Approximately What Date Did You Move Out? Text field
Date You Would Like To Schedule A Tour (tours not required): Text field
Estimated Length of Stay At New Spirit:* Client estimated length of stay
Your Sobriety Date (date of last use):* Text field
If Enrolled in IOP, Where Will You Be Attending: Text field
IOP Start Date (list date): Text field
Current Employment: Text field Occupation: Text field
How Will You Be Paying For Your Housing:* Text field
Criminal History
Have You Been Accused or Convicted Of: Arson?* Radio buttons Sex Crimes?* Radio buttons
Have You Ever Been Convicted Of Physical Violence?* Radio buttons
List Details On ALL Arrests, Convictions, Prison/Jail Time, Probation History, Pending Charges, and Probation Officer Infomation:*
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Medical History
Diagnosis (Include Mental Health):* Text field Substance of Choice (List All):* Text field
Allergies (food, medication, cats): Text field Last Relapse Date:* Text field
Why Did You Relapse:* Paragraph
How Many Times Have You Been Through Treatment: Text field
Were you released from another sober house in the past 30 days: Radio buttons
If yes, please explain circumstances in detail: Paragraph
Have You Ever Planned or Attempted Suicide In The Last Three Years:* Radio buttons
Do snore loud enough to keep a roommate from sleeping (we will do our best to put you with other snorers):* Radio buttons
Referred By
How Did You Hear About Us:* Text field
Treatment Information
Treatment Center:* Text field Counselor Name:* Text field
Counselor Phone: Text field Counselor Email: Text field
Emergency Contact Information
Name: Text field Phone: Text field
Relationship: Text field Email: Text field
Sponsor Contact Information
Name: Text field Phone: Text field
Type: Text field Email: Text field
Medication:
List all medication you currently take or know you will be taking while living at New Spirit Homes/American Sober Living.
Prescription Medication #1
Medication: Text field Dosage: Text field Quantity: Text field Frequency: Text field
MD: Text field Notes: Text field
Prescription Medication #2
Medication: Text field Dosage: Text field Quantity: Text field Frequency: Text field
MD: Text field Notes: Text field
Prescription Medication #3
Medication: Text field Dosage: Text field Quantity: Text field Frequency: Text field
MD: Text field Notes: Text field
Prescription Medication #4
Medication: Text field Dosage: Text field Quantity: Text field Frequency: Text field
MD: Text field Notes: Text field
Other Medications List Here: Text field
Why have you decided to live in a Recovery Residence (Soberhome)?
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Do you have any questions for us?
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Download a copy of your application as it has our contact information. By submitting this Application you state that all information provided is true and accurate. You understand that false information or failing to disclose requested information will result in discharge from the New Spirit Homes Sober Living Program and forfeiture of your sober deposit. You agree that you have filled out this application with honesty and integrity. Thanks--way to go!
Below is a list of things you will need to bring with you. If you need us to lend you any of the below items, just let us know IN ADVANCE:
You must make contact with the House Leader to make move-in arrangements. DO NOT SHOW UP WITHOUT A SCHEDULED MOVE-IN DATE AND TIME.
Bring food with you for the first few days. Meals are not provided; you prepare your own meals. Plates, silverware, and pots & pans are all provided for you.
Small lockbox for all medications, including aspirin. All medications must be in their original prescription bottle, and you must have a current prescription for them.
Personal care products (soap, shampoo, razor, towel, etc.)
U-type lock for your bike, if you are bringing one. Other types of locks are ineffective.
Clothes for two weeks with hangers There are High-Efficiency FREE washers and dryers at each house.
Only the shoes you wear on a regular basis.
Sheets, mattress cover, and comforter for a twin bed. Pillow and pillowcase.
A positive attitude and the passion to remain free from drugs and alcohol.
Do not bring furniture or large items to store such as musical instruments. There is storage available for your suitcase.