Welcome to the Hensley House Application Wizard 🪄
Thank you for considering Hensley House Sober Living Home!
So that we can help provide you with the best possible fit for where you are in the recovery process, please complete the New Resident Application Form below.
The collected registration data is kept strictly confidential.
👇IMPORTANT - PLEASE READ👇
Before filling this applicatioin in please note: Hensley House is a MALE ONLY facility and we do not allow any medically assisted treatment (MAT) medications in the house. The only exception to this is Sublocade. If you are currently taking Suboxone, you would need to switch to Sublocade PRIOR to entry. Additionally, we do not allow any "scheduled" medications of any kind in the house for any reason. If you are prescribed any scheduled medications, understand that you will have to switch that to a non-scheduled alternative PRIOR to arrival. If you are unsure if your medications are scheduled, please look them up using the website www.dea.gov for a full list of scheduled medications. Also please be aware that our house meetings are held on Sunday evenings and attendance at these meetings are mandatory regardless of work schedules. We do not allow overnight shifts and only trained chefs are allowed to work in the food and service industry. And lastly your employment cannot keep you out past curfew. If your current employemnt would have you out past curfew, you'll be given one week after arrival to get changed to a different shift.
If you've read and understood the above notice and would like to continue, click next to begin!
General
Tell us about yourself
What is your first name? *(Please put your first and last name as they appear on your driver license)
Client first name
What is your last name?
Client last name
When is your birthdate?
Client birthdate
What is your gender?
Client gender
What is your marital status?
Client marital status
For Those Currently In Treatment
If you are currently in a treatment center and don't have regular access to your phone, list a contact person at the treatment center or a friend or family member we can call to discuss your sober living options.
Contact
Medical History
Tell us about your medical history.
What is your sobriety date?
Recovery history 1 relapse date
What is your substance(s) of choice? Add multiple by clicking in the box and selecting different options
Client substances of choice
Have you been clinically diagnosed with anything? Add multiple by clicking in the box and selecting different options
Client diagnosis
Have you ever been diagnosed with a traumatic brain injury (TBI)?
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If you answered yes to the previous question, please explain the details surrounding the diagnoses. (eg. When diagnosed, what caused it, problems and/or issues you've had because of it, have you received any treatment for it, what is the current status of the diagnoses, etc.)
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Do you have any health problems? Add multiple by clicking in the box and selecting different options
Client health problems
Have you ever been hospitalized or institutionalized for attempted suicide or having suicidal ideations?
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Are you an insulin dependent diabetic?
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Have you ever been diagnosed with COPD? (Chronic Obstructive Pulmonary Disease)
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Are you currently taking any MAT (Medically Assisted Treatment) medications? (eg. Suboxone, Sublocade, Methadone)
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Are you currently taking any "scheduled" medications? (ie. are you prescribed any narcotic medications such as Adderal, Xanax, Alprazolam, Anabolic Steroids, Ambien, etc.)
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If you checked "yes", please write the name of the medication.
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Legal
Have you ever been convicted of any sexual related offenses or child abuse related offenses?
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Pet Owners
Hensley House is a dog friendly house. There are a limit of 3 dogs allowed in each house. Each dog must be properly house broken and must get along with other dogs. Each dog must be spayed or neutered PRIOR to entry. Proof of all current shots and vaccinations is required as well as monthly flea, tick, and heartworm medication. No dogs allowed under 1 year old. Each dog owner must provide a crate for their dog. All dogs will undergo a one to two week "trial" period to see if they are house broken and if they get along with other dogs.
Are you wishing to bring your dog with you?
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If you answered yes, what is your dog's name?
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Treatment Center/s
Tell us about the most recent treatment center you've been admitted into. If you don't have all the details of the most recent treatment center you've been to, please list the name of the treatment center, what city and state it was in, your best guess of when it started and ended, the type of treatment center, and the reason for discharge. Additionally, if you are currently in a treatment center, please list the details of the current facility you are in.
TreatmentCenterHistory
Client Referral Source
Who referred you to us?
*if you see the name of your referral source in the drop down list, click on that name. Otherwise, please type in the name of the referral source in the box.
Client Referred By
Occupancy
What date would you like to move into Hensley House?
Date
The minimum length of stay at Hensley House is 3 months (90 days). Are you willing to commit to staying at Hensley House for a minimum of 90 days?
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Will you be able to provide a clean urine sample when you arrive?
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