Application for Admission

Application for Admission 

DO NOT LIE, we understand there are situations that may sound terrible but don't think that it will automatically exclude you. However, if you lie on this form you will be denied and we verify all information that you give to us.

Name: Client first nameClient last name

Have you ever applied to or lived at an Obtainable Sobriety house? Radio buttons

If so When? Text field

Current Address: 

Street: Client Address

City: Client City State: Client State Zip Code: Client Zip

Phone: Client phone Email: Client email Date of Birth: Client birthdate 

Contact Person for Case Manager or Program(if applicable) : Text field

Contact Phone Number for Case Manager or Program(if applicable) : Text field

Height: Text field Weight: Text field Hair Color: Text field Eye Color: Text field  

Distinguishing Marks (tattoos, scars): Text field

 

Substance Abuse Information 
(This information is confidential and will not affect your application)

Please list in order of preference all drugs used; past to present. This must be completed

Age at first use Text field Amount used at peak Text field

Drugs: 

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Have you ever lived in a sober house before: Radio buttons

If yes Name: Text field Where: Text field When: Text field How long: Text field Why did you leave: Text field

Have you ever been in a treatment program: Radio buttons

If yes Name: Text field Where: Text field When: Text field How long: Text field Did you complete: Text field

If no Why did you leave: Text field

Do you consider yourself an alcoholic/addict: Radio buttons

Do you currently have a sponsor: Radio buttons

Are you currently attending AA/NA meetings: Radio buttons

If yes, how many per week: Text field

Date of last use of drugs or alcohol: Date

Please be prepared to provide your most recent drug screen info

Legal Information

 

Are you on an intense probation: Radio buttons

If yes, what is your current offense: Text field

List all prior/current convictions: 

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Date of Disposition: Date

Have you ever committed/been charged with arson: Radio buttons

Have you ever been charged with cruelty to animals: Radio buttons

Have you ever been charged/convicted of a violent crime: Radio buttons

Have you ever committed/been charged with a sexual crime: Radio buttons

Financial Information: 

Do you have the funds to cover the rent: Radio buttons

Do you have a legal ID: Radio buttons

Do you currently have a job: Radio buttons

If yes, full time/part time: Text field Name of company: Text field Supervisor's Name: Text field 

Telephone: Text field 

How long have you been employed: Text field

Do you have a current valid Driver's License: Radio buttons

Do you have your own vehicle: Radio buttons

If you don't have a vehicle, how do you intend to get to and from work (buses come by the house often): 

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Are you court ordered to pay child support: Radio buttons

Amount: Text field

Are you behind: Text field

Do you receive any ongoing financial reimbursement for any reason (SSI, Disability, etc): Radio buttons

If yes, explain: Text field

If for some reason you cannot pay rent per week who can you call to help you

Name: Text field Phone: Text field

Educational Information: 

Checkboxes

Last Grade Completed: Text field Years of College Completed:Text field  Educational Goals:Text field 

Medical/Mental Information: 

 

Are you currently on medications: Radio buttons

If yes, list them below

Medication

Have you ever been tested for HIV: Radio buttons

Dates: Text field Results: Text field

Have you ever been a victim of a violent crime: Radio buttons

If yes, please explain: 

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Important Notice: The nature of Obtainable Sobriety requires expulsion, without prior notice or refund any deposits, of any member who is found by the proprietors who the lease on the property to: 1) be using alcohol or drugs or 2) be in default of weekly house share of expenses or 3) be guilty of disruptive or any behaviors that threaten the wellbeing of the property and/or the other members that reside at Obtainable Sobriety. A member of Obtainable Sobriety is a member of the residence. 

I have read the above notice and understand that I am applying for a bed in Obtainable Sobriety as a member of the sober housing. I agree to abide by Obtainable Sobriety's principles and fully subject myself to the rules and expectations of this house including periodic drug testing. I understand that I am subject to immediate expulsion from the house by the proprietors who hold the lease on the property if any of the following occur. 1) Use alcohol or drugs (other than prescribed medications; 2) I fail to pay my weekly house share of expenses and or fees; 3) I engage in disruptive and or any behaviors that threaten the wellbeing of the property and/or the other residents who reside at Obtainable Sobriety.

By signing below, I certify that the information contained in this application is true, I understand and accept the conditions set forth above membership in Obtainable Sobriety, and that I agree to abide by said conditions should I be accepted as a resident of Obtainable Sobriety. *Obtainable Sobriety members must be eighteen (18) years old at the time of admissions. 

Date: Date Signature: Signature

 

All Obtainable Sobriety members MUST pay first week and last week fees BEFORE they will be permitted to move into the house. $175/week. Proof of income verification is necessary.