International Abba Ministries - A Sober Living Community

A Hand up for those struggling

This application is for internal use only. The questions are designed to assist us in utilizing our resources to assist you in your recovery through accountability and aiding you in any obstacles you may need to overcome.

Print Legal Name: Client first nameClient middle nameClient last name
Date of Birth: Client birthdate

Home address ONLY: 

Street:Client Address 
City: Client City  State: Client State  Zip: Client Zip

Information Where You Can Be Reached
Cell: Client phone
Home: Text field
Email: Client email

Emergency Contact:

Contact

Identification Numbers
Social Security Number :SSN
Driver’s License Number: Text field  State:Text field   
Or
ID Card Number:Text field  State:Text field  

Will you have your own transportation? Radio buttons
Vehicle Identification if any.
Paragraph

  
Do you have health insurance?  Radio buttons      Insurances     

Personal Information 
Marital status Radio buttons     Children Radio buttons   
Are you currently receiving SSI, Disability or other non-job related income? Radio buttons
Who will be financially responsible for your Initial fee? Radio buttons
Do you currently receive EBT Benefits? Radio buttons
If Yes:
How much and date of renewal:Text field

Are you employed? Radio buttons
If Yes:
Name of employer:Text field    Contact Number: Text field   

Are you a recovering:
Alcoholic: Radio buttons   Drug addict: Radio buttons    
Sobriety date: Date

List drugs you used addictively:
Client substances of choice

Are you discharging from a substance abuse treatment program, either in-patient or out-patient?   Radio buttons

If Yes:
TreatmentCenterHistory
Counselor: Text field
Phone Number: Text field
Email: Text field

If No:
Current Location if different from Home Address above:Text field
Address:Client Address  City: Client City  State: Client State   Zip: Client Zip
Phone Number:Text field
Move in Date: Date

Are you participating in or about to enter a methadone or other drug replacement program? Radio buttons

Do you take prescription drugs?  Radio buttons
If Yes, list prescription drug & reason for prescription on page 6 of the “Plan and Path”. I understand that I am responsible for my medication regimen and will not hold IAM responsible for anything dealing with my prescription drugs. Initial Initials Text field

Do you have any current court case pending, other than moving violations? Radio buttons

Have you ever been convicted of a felony? Radio buttons
If Yes:
Violation: Checkboxes

County: Text field  City:Text field  State:Text field
If Yes, explain:Paragraph

Have you ever lived in a sober house before? (i.e. Oxford House) Radio buttons

Initial Initials Text field I understand that the House I am applying to requires complete abstinence from drugs and Alcohol. Discourteous behavior towards staff or residents will not be tolerated. Clients must meet financial obligations. Failure in any of these areas may result in immediate eviction from the premises.
All rules regulations and requirements listed in the “Plan and Path” are part of this application Initial Initials Text field
By signing the application below, I authorize IAM to utilize the above information to process my request for membership.

Printed Name of Applicant: Text field

Signature of Applicant: Signature
Date:Date