Men's Long-Term Sober Living Home Application for Admission
Today's Date: Date
Potential Entry Date Requested: Date
What agency or facility referred you? Client Referred By
Contact Information
Applicant Name: Client first nameClient last name
Street Address: Client Address
City, State, Zip: Text field
Phone Number: Client phone
Email: Client email
Date of Birth: Client birthdate
Marital Status: Client marital status
Gender: Client gender
Ethnicity: Client ethnicity
Military History: Client veteran status
Emergency Contact Information
First and Last Name: Contact
Relationship to you: Text field
Phone Number: Text field
Medical History
Are you currently under the care of a physician?
Radio buttons
If yes, what is the name of your physician? Text field Phone#: Text field
Date of last doctor's appointment: Text field
Please list all medications you are currently taking or are prescribed to take: Medication
Please list all allergies: Client allergies
Current or past physical medical problems (please list all diagnoses)? Client health problems
Do you have a history of...
Seizures?
Radio buttons
If yes, dates: Text field
Diabetes?
Radio buttons
If yes, dates: Text field
Tuberculosis (TB)?
Radio buttons
If yes, dates: Text field
Hepatitis?
Radio buttons
If yes, dates: Text field
HIV/AIDS?
Radio buttons
If yes, dates: Text field
Have you ever suffered from depression, anxiety, or other serious mood disturbances?
Radio buttons
Any diagnosis of schizophrenia or other psychological disorder?
Radio buttons
If yes, please list here: Client diagnosis
What, if any, are your concerns about emotional/mental well-being?
Paragraph
Do you experience suicidal thoughts?
Radio buttons
Do you use tobacco?
Radio buttons
Alcohol / Drug History
Please list ALL mood-altering substance use/ drugs of choice:
Client substances of choice
Any family history of alcohol/drug use?
Radio buttons
Please list anything else you would like us to know about your drug/alcohol abuse history:
Paragraph
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 History
Are you currently employed?
Radio buttons
If yes, please list the name of your employer: Text field Employer Phone# Text field
Please list your employment history here:
EmploymentHistory
Legal History
Please list all current/pending charges and past convictions including sexual offenses:
Charge: Text field
Date: Date
Sentence / Outcome: Text field
Charge: Text field
Date: Date
Sentence / Outcome: Text field
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.