Men's Long-Term Sober Living Home Application for Admission
Applicant Name:Client first nameClient last name
Today's Date: Date
Potential Entry Date Requested: Date
Why do you want to come to LIT?
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Are you currently applying from an inpatient treatment facility?
Radio buttons
If yes, what is the name of the facility you are at? Text field
If yes, what is the name and phone number of your case manager? Text fieldText field
If no, what is your current living situation?
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What phone number can you currently be reached at? Text fieldText field
Applicant Information
Street Address:
Client AddressClient CityClient StateClient Zip
Cell Phone Number:
Client phone
Email:
Client email
Date of Birth:
Client birthdate
Marital Status:
Client marital status
Sex at Birth:
Client gender
Military History:
Client veteran status
Medical History
Are you currently under the care of a physician?
Radio buttons
Please list all medications you are currently taking or are prescribed to take:
Medication
Please list all allergies:
Client allergies
Current or past medical issues (please select all diagnosis that apply)?
Client health problems
Do you have a history of seizures, schizophrenia, bipolar disorder, or any other psychological disorder?
Radio buttons
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What, if any, are your concerns about your emotional/mental well-being?
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Have you been experiencing suicidal thoughts?
Radio buttons
Alcohol / Drug History
Please list ALL mood-altering substance use/ drugs of choice:
Client substances of choice
Are you taking any of the following?: suboxone, methadone, sublocade, brixadi, marijuana/THC
Radio buttons
Please list anything else you would like us to know about your drug/alcohol abuse history:
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Criminal History
Criminal History
Have you ever been convicted of an arson or sex offense?
Radio buttons
Do you have any Open 241 Kids or Child Protective Services cases?
Radio buttons
If you are currently on probation, please list:
Probation
Treatment/Sobriety History
Most recent treatment facilities attended: TreatmentCenterHistory
Most recent sober living facility attended: SoberLivingHistory
Education History
Highest grade completed: Text field
Degree/Diploma?
Radio buttons
GED?
Radio buttons
Employment Status
Are you currently employed?
Radio buttons
Please review your application and make sure all fields have been filled out. Upon completion, please sign below and click "Submit Form". Your application will then be sent to the Housing Director for review. Please call 513-276-6304 opt#3 to follow up with the status of your application. Thank you.
Please sign your name below:
Signature
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.