RESIDENT APPLICATION                                                           Date: Date

Contact Information  

Full Name:Text field

Preferred Name:Text field

Date of Birth:Date
Phone Number: Text field
Email Address: Text field
Primary/Permanent Mailing Address:
Text field

Where Are You Now?Text field
Support Person (Name, Relationship, Phone #): 
Text field

Emergency Contact (if different than above): 

Text field

Attestation: 

I have received, read, and understand The Launch Pad Information/FAQ packet. 

Please initial to confirm: 

 Text field

 

Substance Use History

Substance(s) Used & Primary Drug of Harm:
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How has substance use impacted your daily life? Paragraph

Age of 1st Use? Text field
Date of Last Use? Text field
Previous Treatment Programs (if any): 
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History of Overdose/Blackouts (Yes/No, Details):
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Medical History

Medical Conditions (e.g., chronic pain, diabetes, hypertension, seizures etc.): Paragraph
History of Surgeries, Hospitalizations, or Major Illnesses: Paragraph
Allergies (Food, Medication, Pets): Text field
Primary Care Physician Name & Contact Info:
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Physical Disabilities or Limitations: Text field

Mental & Behavioral Health History

History of Mental Health Diagnoses (e.g., depression, anxiety, PTSD, schizophrenia):Text field
History of Psychiatric Hospitalizations or Crisis Intervention:
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History of Self-Harm or Suicidal Thoughts:
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Cognitive Disabilities/ Learning Disabilities: 
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If you answered YES to any of the above questions, did you receive this diagnosis while in active addiction?

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Medications

Current Prescription Medications & Reasons Prescribed:
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History of Medication Misuse (if applicable): 
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Family History

Immediate Family Members Including Children & Relationships: Paragraph
Are There Current Child Custody Issues?  Text field
Is There a Family History of Substance Use or Mental Health Disorders?
Text field

Who In Your Family Supports Your Recovery?Text field
Do You Have Family Members in Active Addiction or in Recovery? Paragraph
Is There Any History of Domestic or Family Violence?  Paragraph
Legal History

Any Pending Charges or Court Cases? Text field
Is Sober Living Court Ordered? Text field
Probation or Parole Status (include contact information if applicable): Text field
History of Incarceration (if applicable): Paragraph

Employment and Education

Current Employment Status: Text field
Employer Name & Contact Information:Text field

Do you receive government funding of any kind? Paragraph

Highest Level of Education Completed? Text field

Financial Information

How Will You Be Paying for Housing?  Text field
Do You Have a Bank Account? Text field

Support System and Recovery Goals

Do You Have a Sponsor? Text field
Support Groups Attended (AA, HA, NA, SMART Recovery, etc.): Text field
Personal Recovery Goals: Paragraph

Living Arrangement and Program Expectations

History of Sober Living Experience
Have You Previously Lived in a Sober Living House?  Text field
If Yes, Name and Location of Previous Residence(s):
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Length of Stay in Previous Sober Living Environment(s):
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Reason for Leaving? Text field
What Worked Well in Past Sober Living Experiences? Text field
What Challenges Did You Face?  Text field
Can We Contact the Previous Sober Living Residence?Text field
Are You Willing to Abide by House Rules?Text field
Are You Open to Random Drug Testing? Text field
Do You Have Any Special Living Needs? Paragraph
Do You Have a Driver's License?Text field
If NO, Are You Willing to Ride the Bus Daily for Work?Text field

Referral Information

How Did You Hear About Us? Text field
Referral Source (if applicable): Text field

Agreement and Signature

Applicant Signature:Signature
Date:Date

Please Tell Us Why You Want to be a Part of The Launch Pad Sober Living Community: Paragraph