Legacy Sober Living Homes
Resident Application
Resident Information
Name Client first nameText fieldClient last name Move-in availible Date Date SS#Text field
Street AddressClient Address Apt#/Unit Text field CityClient City State Client State Zip Client Zip
Phone# Client phone Email Client email
Gender: Client gender Age Text field DOB Client birthdate
House Assignment Text field Sobriety Date Date Program Working Text field
Willing to attend Support meetings? Text field Willing to get Sponsor? Text field
How many attempts have you made to get clean in the past? Text field Most clean time attained Text field
Have you ever been incarcerated? Text field Duration Text field Release date Date
DOC# Text field State Text field Registered Sex Offender in any State Radio buttons
Charges Text field Currently on probation/parole? Text field
Date of completion Date Probation/parole Officer Name Text field
Are you currently on any medications? Text field Prescribed by a licensed professional? Text field
List all medications (Name of medication, dosage, and frequency of dosage)
Medication
Why are you seeking housing at this time?
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List names and dates of any treatment programs, shelters, recovery and halfway houses, previously attended
TreatmentCenterHistory
We require a letter of approval from the Counselor/Therapist you are presently working with. Please let them know to expect a call from us.
Counselor NameText field Phone#Text field
EMERGENCY CONTACT INFORMATION
Contact
MILITARY SERVICE
Branch Text field From Date To Date
Rank at Discharge Text field Type of Discharge Text field
SUBSTANCE HISTORY
Drug of Choice Client substances of choice Duration of Use Text field
DISCLAIMER AND SIGNATURE
All applications will require payment of a $50 non-refundable application fee – in the event an applicant accepted and moves into a Legacy house, the application fee and costs for drug testing will be deducted from the first week of rent. Upon move-in, residents pay their last week of rent ($170) $50 application fee and any costs of drug testing at an independent lab. Must give a one week notice of transitioning out of the Legacy sober home.
I understand my responsibilities as a house member:
1. To actively participate in the development of a recovery plan, mutually designed by myself and SVVOR Coaches (including but not limited to attendance at 12 step/support meetings daily for the first 30 days, and actively working a recovery plan, keeping any appointments as they apply to the plan, and to inform house leadership as soon as possible when appointments cannot be met).
2. To follow House Rules and Expectations
3. To attend MANDATORY house meetings on Sundays at 6PM. If I cannot make a house meeting or will be late, I will notify house leadership immediately. Being excused from a house meeting will be at the discretion of house leadership.
4. To be responsible for all debts accrued (House Dues $170 per week; Weekly Floor Bill $10)
I agree that house dues paid to Legacy Sober Living Homes will be paid on Sundays by 6pm in- advance. I also agree that whatever money I have paid for service to Legacy Sober Living Homes will be Non-Refundable due to relapse or if asked to leave by house leadership for behavioral reasons or for violation of House Rules and Expectations (See pages 5 -7). A refund may be given only if more than 1 week was paid. No other refunds will be made.
Legacy Sober Living Homes reserves the right to move or dispose of any and all Residents’ personal items and belongings to storage at any time if said Resident is no longer a resident at Legacy Sober Living Homes for any reason.
Legacy Sober Living Homes reserves the right to decline or refuse services to any person at any time for any reason.
The undersigned gives permission to staff of Legacy Sober Living Homes and Sauk Valley Voices of Recovery to conduct nationwide background checks for credit issues, legal and sex offender status upon application for admission and periodically during the resident’s stay. Evidence of violent crime or sex offender status will disqualify the resident from continued presence in the home.
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I certify that my answers are true and complete to the best of my knowledge
By signing below, I am confirming that I have read and understand the above policy. I willingly consent to the disclosed policies and procedures listed in regards to services rendered by Legacy Sober Living Homes.
By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.
Printed Resident Name Text field
Resident Signature Signature Date Date