Application for Membership to Purpose House
To become a resident in a Purpose House you must contact the individual house and schedule an interview and be accepted.
You may print this application and bring it with you. DO NOT SEND THIS TO PURPOSE TLC. You must bring it to the house for your interview.
1. Name: Resident first name Resident middle name Resident last name
2. Date of Birth: Resident birthdate
3. Current Address Resident mailing address
4. Phone where you can be reached Text field Work Phone Text field
5. Are You an Alcoholic? Dropdown 6. If Yes, when was your last drink Date
7. Are you a Drug Addict? Dropdown 8. If YES, when did you last Use? Date
9. What are your Drug(s) of Choice? Resident substance of choice
10. When Did you attend your First 12-Step Meeting (NA, AA, Nar-Anon, etc) Date
11. How Many Meetings do you attend each week? Dropdown
12. Do You Want to STOP Drinking and/or Using Drugs? Dropdown
13. Are You Currently Employeed? Dropdown If YES who is your employer? Resident current employment
If NO, when was the last time you were employed on a Full time basis Date
14. Do You Recieve any Form of Government Assistance? Dropdown
15. If You Don't Have a Job, what are your plans for getting One? Dropdown
16. What is your Monthly Income? Text field
17. What do You Expect Your Monthly Income to be Next Month? Text field
18. What is Your Marital Status? Dropdown
19. Do You have a Medical Doctor? Dropdown If Yes, when was the last time you saw him/her? Date
20. Have You ever been to a Treatment Facilty for Alcohol or Drug Addiction? Dropdown If YES, Please provide the Floowing Information
Treatment center 1 name From Treatment center 1 started to Treatment center 1 ended Reason for Leaving Dropdown
Treatment center 2 name From Treatment center 2 started to Treatment center 2 ended Reason for Leaving Dropdown
21. Do You Take Presciption Drugs? Dropdown If YES, list Drug and the Reason it has Been Prescribed.
Medication 1 name Medication 1 notes
Medication 2 name Medication 2 notes
Medication 3 name Medication 3 notes
22. When do you want to Move in? Dropdown If OTHER, List the date that you want to move in if accepted and why the date is in the future, rather than IMMEDIATELY.
Move In Date: Date
Reason: Paragraph
23. Have you Ever Lived in a Purpose House Before? Dropdown If YES, Provide the Name and Location of the Purpose House and Answer Question #24.
Paragraph
24. [Answer this Question ONLY if your answer to Question #23 was YES]
I left Purpose House for the Following Reason Dropdown If "OTHER" Please explain Text field
I owe Money to the Purpose House that I left Dropdown If YES, how much do you owe? Text field
If you do Owe Money to another Purpose House, do You agree to pay the money you owe to the Previous Purpose House? Dropdown
25. Contact Phone Numbers [List Family Doctor, (if you have one) and Two Family Members]
Contact 1 name Contact 1 phone Contact 1 type
Contact 2 name Contact 2 phone Contact 2 type
Contact 3 name Contact 3 phone Contact 3 type
26. Please Read the Following Statement and Intial, indiacting that you have Read and Fully Understand it.
I realize that the Purpose House to which I am applying for residency is a "Structured" Sober/Tranistional Living Environment and has been established in Compliance with the conditions of §2036 of the Federal Anti-Drug Abuse Act of 1988, P.L. 100-690, as amended, which provides that federal money loaned to start the house requires the house residents to (A) prohibit all residents from using any alcohol or illegal drugs, (B) expel any resident who violates such prohibition, (C) equally share household expenses including the monthly lease payment, among all residents, and (D) utilize democratic decision making within the group including inclusion in and expulsion from the group. In adition, there are other specific Rules and Regulations in place regarding code of conduct and active participation in Recovery Programs. In accepting these terms, the applicant understands that §2036 conditions are different than the normal due process afforded by some local landlord-tenant laws. Text field
27. Provide any additional Relevant Information that you may want the Purpose House You are Applying for here.
Paragraph
28. I Have Read all of the Material on this Application form, Including the Limitations Set-Forth in Item #26, I have also Answered each Question Honestly and I want to Acheive comfortable Recovery from Alcoholism and/or Drug Addition without Relapse.
Signature Date Date