AMOS SOBER LIVING MEMBERSHIP APPLICATION
Email: info@ashagj.com
Office phone (970) 985-4041
Fax: (970) 241-2282
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APPLICATION PROCESS
1. COMPLETE APPLICATION AND SUBMIT FORM
2. COMPLETE INTERVIEW WITH PROGRAM MANAGER or BUSINESS OPERATIONS DIRECTOR
3. IF ACCEPTED, ARRANGE TIME AND DATE OF ARRIVAL
Please note: An acceptance letter will be provided pending acceptence into acceptance and provided upon request of the member
Referral Source: Text field
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GENERAL INFORMATION
Name: Client first nameClient last name
Date of Birth: Client birthdate
Phone Number: Client phone
Email: Client email
Current Address: Client AddressClient CityClient StateClient Zip
Gender: Client gender Client pronoun
Gender Identity: Dropdown
Sexual Orientation: Dropdown
Race/ Ethnicity: Client race
Marital Status: Client marital status
Military Status: Client veteran status
Health Insurance?Dropdown
Insurances
What is your current employment status:
Dropdown
EmploymentHistory
Are you currently receiving SSI/ SSDI? Dropdown
Source of income (if not wages or disability): Text field
Salary (Weekly/Monthly): Text field
In the last 30 days where have you been living?
LivingArrangementHistory
Who will be your emergency contact while in the program:
Contact
Please Answer all of the following forms of identification (ID) which you have in your Possession
Social Security Card: Dropdown Number: Text field
Driver’s License: Dropdown Number Text field State Text field
State Picture ID: Dropdown Number: Text field State Text field
Birth Certificate: Dropdown Number: Text field State Text field
EducationHistory
Do you own a vehicle? Dropdown
If yes will the vehicle be with you? Dropdown
If yes to having a vehicle with you while in program please provide the following information below:
What is the License Plate Number? Text field
Vin Number Text field
Do you have Auto Insurance?
Checkboxes
Insurance provider name: Text field
Policy Number: Text field
Are you required to Ignition Interlock?
Checkboxes
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MEDICAL INFORMATION
How long have you been sober? Text field
Client substances of choice Other: Text field
Below fill in any previous treatment and recovery history we should know about:
RecoveryHistory
TreatmentCenterHistory
SoberLivingHistory
Client kinds of meetings attended
Have you been diagnosed with any Mental Health conditions?
Dropdown
If Yes select a diagnosis
Client diagnosis
List any medical conditions you currently have: Text field
List of current prescription medications you are taking: Client medical notes
Other Current Illness/ Disability: Text field
Are you physically independent and able to perform daily activities such as showering, using the restroom, walking without assistance, and getting in and out of bed on your own?
Checkboxes
If No, please explain below in further detail so we can better understand your needs:
Paragraph
Do you require any special accommodation?
Checkboxes
If yes what accommodations:
Paragraph
*Please keep in mind we are not a medical facility and there are certain accomidations we may not be able to provide*
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Legal History
Are you court ordered to live in a Sober living Environment/ Halfway House?
Dropdown
Are you currently involved in any legal action? Dropdown
If “Yes” please explain:
Text field
Are you required to register as a sex offender? Dropdown
State of Registry: Text field
Have you been accused/ convicted of a Sex Offence? Dropdown
Have you ever been convicted of arson? Dropdown
A felony? Dropdown
If yes How many and what were the charges? Text field
Do you have any legal charges pending? Dropdown
if yes list court dates and charges Text field
Probation/ Parole: Dropdown
(A copy of probation/ parole details must be provided)
Probation/ Parole officer (if known): Text field
Phone: Text field
Address Text field
Email Address (if applicable): Text field
If incarcerated, what is your earliest projected release date Date
How long incarcerated: Text field
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Please answer the following questions to help us consider your application into the program.
What are you expecting to get out of the sober housing program?
Paragraph
Please provide three attainable goals you want to work towards when approved for enrollment:
1. Paragraph
2. Paragraph
3. Paragraph
Are you able to pay the $715 move in cost?
Checkboxes
If you have funding lined up please provide details:
Text field
Requested sober living start date: Date
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AMOS SOBER LIVING MEMBERSHIP APPLICATION IMPORTANT NOTICE:
Amos Sober Living is a recovery home which enforces expulsion, without prior notice or refund of deposit and fees, of any resident member who is found to be:
1) using alcohol or drugs.
2) engaging in disruptive behavior; or
3) in default of payment of monthly membership fee.
All members of Amos Sober Living are members of our recovery facilities. You do NOT have renter’s rights or any rights of tenants pursuant to the Colorado Property Code, and expressly waive any such rights in exchange for membership privileges.
I have read the above notice and understand that I am applying for membership of Amos Sober Living as a member of a recovery facility. I agree to abide by the responsibilities and requirements of the house and fully subject myself to the rules and expectations of the home, which include periodic/random drug testing.
I understand that I am subject to immediate expulsion from the home if any of the following occur:
1) I use alcohol or drugs (other than prescribed medications); 2) I engage in disruptive behavior (continued patterns of irresponsible behavior are considered disruptive behavior); 3) I fail to pay my monthly membership dues.
SIGNATURE of APPLICANT: Signature
DATE: Date