RESIDENT INTAKE APPLICATION

OFFICE USE ONLY
Date Application Received: Date
Interview Date: Date
Reviewed By: Text field
Admission Status:
Checkboxes Accepted
Checkboxes Accepted with Conditions
Checkboxes Waitlisted
Checkboxes Denied
Move-In Date: Date
Room Assignment: Text field

SECTION 1: APPLICANT INFORMATION

Full Name: Text field
Preferred Name: Text field
Date of Birth: Date
Phone Number: Number field
Email Address: Text field
Current Address: Text field

Emergency Contact Name:

Relationship: Text field
Phone Number: Number field

SECTION 2: IDENTIFICATION

Driver's License / State ID Number: Text field

State Issued: Date

Social Security Number: Number field

Do you currently have:
Checkboxes Valid ID
Checkboxes Social Security Card
Checkboxes Birth Certificate
Checkboxes Vehicle Registration
Checkboxes Proof of Insurance

 

SECTION 3: LEGAL INFORMATION

Are you currently:
Checkboxes On Probation
Checkboxes On Parole
Checkboxes Neither
Officer Name: Text field

Officer Phone: Number field

Expected Release Date (if applicable): Date

Have you ever been convicted of a violent offense?
Checkboxes Yes
Checkboxes No
If yes, explain: Text field

Are you currently required to register as a sex offender?
Checkboxes Yes
Checkboxes No

SECTION 4: RECOVERY INFORMATION

Primary Substance(s) Used: Text field

Length of Addiction: Text field

Current Sobriety Date: Date

Have you attended treatment before?
Checkboxes Yes
Checkboxes No
If yes, list treatment centers: Text field

Have you lived in sober living before?
Checkboxes Yes
Checkboxes No
If yes, where? Text field

Do you currently have a sponsor?
Checkboxes Yes
Checkboxes No
Sponsor Name: Text field

Sponsor Phone: Number field

Recovery Meetings Currently Attending: Text field

SECTION 5: EMPLOYMENT & FINANCES

Current Employment Status:
Checkboxes Full-Time
Checkboxes Part-Time
Checkboxes Unemployed
Employer: Text field

Monthly Income: Number field

Available Savings: Number field

Do you currently have a bank account?
Checkboxes Yes
Checkboxes No
Do you have reliable transportation?
Checkboxes Yes
Checkboxes No
If no, explain: Text field

SECTION 6: MEDICAL INFORMATION

Medical Insurance:
Checkboxes Yes
Checkboxes No
Provider: Text field

Emergency Medical Conditions: Text field

Current Medications: Text field

Do you require any special accommodations?
Checkboxes Yes
Checkboxes No
If yes, explain: Text field

SECTION 7: PROGRAM COMMITMENT

I understand and agree that Vision Alignment Homes requires:
Checkboxes Sobriety
Checkboxes Random Drug Testing
Checkboxes Employment within 14 days
Checkboxes Weekly Employment Updates
Checkboxes Recovery Meeting Attendance
Checkboxes Sponsor Accountability
Checkboxes Participation in the Map It Out Program
Checkboxes Mandatory Guest Speaker Sessions
Checkboxes Volunteer/Community Service Requirements
Checkboxes Monthly Budget Reviews
Checkboxes Monthly Resident Progress Reviews
Checkboxes Compliance with House Rules

 

SECTION 8: GOAL SETTING
What are your top three goals for the next six months?

 Text field

 Text field

 Text field

Where do you want to be one year from today?

Text field

SECTION 9: READINESS ASSESSMENT

Why are you seeking sober living? Text field

What motivates you to change? Text field

What support systems do you currently have? Text field

What challenges do you believe may affect your success? Text field

 

APPLICANT CERTIFICATION

I certify that the information provided in this application is true and accurate to the best of my knowledge.
I understand that providing false or misleading information may result in denial of admission or immediate discharge from the program.
Applicant Signature: Signature

Date: Date