Legacy Sober Living Homes
Resident Application 

Resident Information

Name Client first nameText fieldClient last name

DOB:Client birthdate SS#SSN     

Street Address Client Address 

Apt#/Unit Text field 

CityClient City    State Client State    Zip Client Zip

Homeless: 

Radio buttons

Phone# Client phone    Email Client email

Gender: Client gender Age Text field

Sobriety Date: RecoveryHistory

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?

List names and dates of any treatment programs, shelters, recovery and halfway houses, previously attended

Paragraph

List names and dates of any treatment programs, shelters, recovery and halfway houses, previously attended

TreatmentCenterHistory

 

 

 

 

 

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) plus $50 application fee and any costs of drug testing at an independent lab. 

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. 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.

 

 

 

 

 

 

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.

 

Printed Applicant Name Text field

Applicant Signature:Signature

Date:Date

 

Printed House Manager Name:Text field

House Manager Signature Signature

Date Date