Brightlife Sober House Resident Application

Criminal History Questionnaire

Full Name:Client first nameClient last name

Date of Birth: Client birthdate

Contact Number:Client phone

Email Address: Client email

Criminal History Information

1. Have you ever been incarcerated? 

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** If yes, please provide details for each incarceration:**

Incarceration 1:

Facility Name: Text field

Dates of Incarceration: Text field

Reason for Incarceration: 

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Were you on probation or parole after this incarceration? 

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Incarceration 2 (if applicable):

Facility Name: Text field

Dates of Incarceration: Text field

Reason for Incarceration:

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Were you on probation or parole after this incarceration?

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 (Repeat the above fields as necessary)

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Probation/Parole Officer Information

 1. Are you currently on probation or parole?

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 **If yes, please provide the following details:**

 Probation/Parole Officer's Name: Text field

Agency:Text field

Contact Number: Text field

Email Address: Text field

Office Address: Text field

Authorization

1. I understand that as a condition of my application to Brightlife Sober House, I must arrange for my probation/parole officer to speak with Brightlife staff.

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2. I agree to facilitate this communication and provide all necessary contact information.

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Signature:Signature

Date:Date