BELOVED HOUSING❤

ATTENDEE APPLICATION

Date:	Referred by: Choose referrer...
Name:	Date of Birth:
Ethnicity: EthnicityDon't see the option you're looking for? Click here	Mobile Phone:
Alternate Phone:	Email Address:
Driver’s License # State:	Highest Level of Education:
Emergency Contact:	Emergency Contact Phone #:

Parole/Probation? (if applicable, please provide Officer Name/#):

Have you previously resided in a Sober Living Home? If so, please detail below:

Sober Living History #1
name:
description:
address:
city:
state:
zip code:
admitted:
discharged:
estimated length of stay:
reason for discharge:
Sober living reason for dischargeDon't see the option you're looking for? Click here

Describe your addiction and length of time you have struggled with your addiction:

Briefly describe your understanding of the 12-Step Recovery Program?

Describe any Parole and/or Probations (include dates and description):

Describe any physical and/or mental health diagnosis:

Describe any physical disabilities:

List any medications:

Medication #1
Name:
Dosage:
Quantity:
Category:
Choose category...Don't see the option you're looking for? Click here
Frequency:
Md:
Notes:
Pill count:
Discontinued at:

Detail any hospitalizations:

Describe any suicide attempts:

List names of All Doctor(s) and Therapist(s):

Name of Doctor/Therapist	Reason for Treatment	Contact Information

Print Name:

Date:

Signature:

Witnessed by:

Date:

Additional Comments:

Questionnaire:

Please write a paragraph detailing your addiction story and path to recovery.

When was the last time you relapsed?

Please describe.

Are you interested in our Faith based program? Have you accepted Christ as your personal Savior?

What does that mean to you?

List residence for last 5 years:

City	Reason for Moving	Landlord Name	Landlord Phone/Email

What do you think would be the most difficult obstacle in your recovery?

CHARACTER REFERENCES (required):

Character References are required. References should reference your character and not be a listing from friends and family members. Suggestions: Past Sober Livings, Boss, Landlord, House Managers, Pastor, Parole Officer, etc…

Name of Reference
Relationship to Reference
Phone Number
Email

Name of Reference
Relationship to Reference
Phone Number
Email

Name of Reference
Relationship to Reference
Phone Number
Email

Name of Reference
Relationship to Reference
Phone Number
Email

Name of Reference
Relationship to Reference
Phone Number
Email

BELOVED HOUSING❤

ATTENDEE APPLICATION

Sober Living History #1

Medication #1

Questionnaire: