Legacy Sober Living Homes
Resident Application 

Resident Information

Name Client first nameText fieldClient last name

Date of Birth:Client birthdate Social Security Number#SSN     

Address: Client Address 

Apt#/Unit: Text field 

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

Homeless: 

Radio buttons

Phone# Client phone   

Email Address: Client email

Gender: Client gender 

Sobriety Date: RecoveryHistory

Program Working Text field

 

Willing to attend Support meetings? Text field   

Willing to get Sponsor? Text field

Most clean time attained Text field

Have you ever been incarcerated? Text field   

Duration? Text field   

State: Text field   

Registered Sex Offender in any State? Radio buttons

Currently on probation/parole? Text field  

Are you currently on any prescription medications? Text field

List all medications (Name of medication, dosage, and frequency of dosage)
Medication

 Why are you seeking housing at this time? Text field

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

Paragraph

 

Our program is self pay, which means we do not accept insurance for your weekly payment of house dues. Do you have any physical or emotional restrictions that would limit you from working a job? If yes, please list them, in detail below.

Paragraph

 

EMERGENCY CONTACT INFORMATION:

Contact Relationship: Text field

Contact Phone Number: Number field

Contact E-mail Address: Text field

 

SUBSTANCE USE HISTORY

Substance of Choice Text field     Duration of Use Text field

 

DISCLAIMER AND SIGNATURE

All applications will require payment of a $50 non-refundable application fee.

I understand my responsibilities as a house member:

1. To actively participate in the development of a recovery plan, mutually designed by myself and a SVVOR Coach. 
2. To follow House Rules and Expectations
3. To attend MANDATORY house meetings. 
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. 

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