Safehouse Sober Living Application

 

Contact Information

 

First Name: Client first name

Last Name: Client last name

Phone Number: Client phone

Is this your phone?

Radio buttons

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 

 

Personal History

 

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? 

Radio buttons 

 

Employment History

 

Are you employed? 

Radio buttons

If yes, who is your employer? EmploymentHistory

 

Residency Planning

 

Are you able to pay $225 upon entering house (deposit- $75 first week of rent- $150.00)? 

Radio buttons

Have you ever lived in a sober living house before? 

Radio buttons

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? 

Radio buttons

 

Acknowledgements

 

How did you hear about Safehouse? 

Text field

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?

 Checkboxes

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

Signature:

 Signature