Men, Women & Women w/ Children (recovery restoration homes)

BELOVED HOUSING❤

 

 

ATTENDEE APPLICATION 

Date: Date	Referred by: Client Referred By
Name: Client first name Client last name	Date of Birth: Client birthdate
Ethnicity: Client ethnicity	Mobile Phone: Client phone
Alternate Phone: Text field	Email Address: Client email
Driver’s License # Text field  State: Text field	Highest Level of Education: Text field
Emergency Contact: Text field	Emergency Contact Phone #: Text field

 

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

 

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

SoberLivingHistory

 

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

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

 

 

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

 

 

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5. Describe any physical and/or mental health diagnosis:

 

 

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6. Describe any physical disabilities: 

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7. List any medications:

Medication

 

8. Detail any hospitalizations:

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9. Describe any suicide attempts:

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

Name of Doctor/Therapist	Reason for Treatment	Contact Information
Text field	Text field	Text field
Text field	Text field	Text field

 

Print Name: Client first name Client last name

Date:  Date

Signature:

Signature

 

Witnessed by: Text field

Signature

Date:  Date

 

Additional Comments:

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Questionnaire:

 

 

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

 

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• When was the last time you relapsed?  

 

Please describe.

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

 

What does that mean to you?

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• List residence for last 5 years:

 

City	Reason for Moving	Landlord Name	Landlord Phone/Email
Text field	Text field	Text field	Text field
Text field	Text field	Text field	Text field
Text field	Text field	Text field	Text field
Text field	Text field	Text field	Text field
Text field	Text field	Text field	Text field

 

 

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

 

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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	Text field
Relationship to Reference	Text field
Phone Number	Text field
Email	Text field

 

Name of Reference	Text field
Relationship to Reference	Text field
Phone Number	Text field
Email	Text field

 

Name of Reference	Text field
Relationship to Reference	Text field
Phone Number	Text field
Email	Text field

 

Name of Reference	Text field
Relationship to Reference	Text field
Phone Number	Text field
Email	Text field

 

Name of Reference	Text field
Relationship to Reference	Text field
Phone Number	Text field
Email	Text field