First Name: Client first name
Last Name: Client last name
Phone Number: Client phone
Is this your phone?
If not, whose phone? Text field
Email: Client email
Current Street Address: Client Address
Current City: Client City
Current State: Client State
Current Zip Code: Client Zip
Are you in recovery from drugs and/or alcohol? Dropdown
What is your sobriety date? Text field
List of drugs you've used actively: Client substances of choice
What kinds of meetings do you attend? Client kinds of meetings attended
Do you currently take prescription drugs?
Are you employed?
If yes, who is your employer? EmploymentHistory
Are you able to pay $225 upon entering house (deposit- $75 first week of rent- $150.00)?
Have you ever lived in a sober living house before?
When would you like to move in? Text field
Estimated length of stay (in months): Client estimated length of stay
Can you pass a drug screen?
How did you hear about Safehouse?
Do you realize the Safehouse home to which you are applying requires that all members abstain from the use of alcohol or any illegal drugs and any member who violates policy will be expelled immediately. All members are responsible for maintaining peace within home and immediate area. Any member who disturbs the peace of Safehouse community will be expelled immediately. In accepting these terms, do you understand that these conditions are different than the normal due process afforded by some local landlord-tenant laws?
By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.
Date: Text field