Jeffrey C. McDonough, INC.
Jeff’s Sober Living – Guest Application
Please provide the information requested below. Failure to fully complete this application may result in having the application rejected. If a bed is available at one of our Sober Living Houses, a staff member will interview you after reviewing this application.
Name:Client first name Client middle name Client last name
Referring Agency nameText field Agency Contact nameText field
Agency PhoneText field
Client Cell Phone Number: Client phone Best way to contact Text field
Date of Birth: Client birthdate Email address Client email
Home Address: Client AddressClient CityClient StateClient Zip
Did anyone refer you to Jeff’s Sober Living?Text field
If so, who and what’s their relation to you? Text field
What date are you seeking to move into a recovery house? Date
What Location are you interested in? You may check more than one, and we'll assign by availability.
Checkboxes Hartford Connecticut Checkboxes New London Connecticut CheckboxesAshtabula Ohio Checkboxes Cleveland Ohio West Checkboxes Willowick Ohio Checkboxes Mentor Ohio Checkboxes Painesville Ohio
Does the applicant intend on applying for any rent subsidies, grants, or scholarships? Text field * Please note that it is the responsability of the applicant to secure any grant, subsidy, or scholarship prior to acceptance and admittance to Jeff's Sober Living.
Emergency Contact Name and Telephone: Contact
Sponsors Name Text field Sponsors Phone Text field
Are you currently working a 12 step recovery program? Text field
Please submit your detailed 5 point recovery plan (required for acceptance) Paragraph
Are you employed? Text field Employment is required for Self-pay Jeff's Sober Living.
EmploymentHistory
Have you been convicted of a felony? If so, list the charge(s) and year(s) for each charge.Paragraph
Have you ever been convicted of a crime of domestic/family violence? If so, list the
charge(s) and year(s) for each. Paragraph
Have you ever been convicted of a crime requiring you to register with a sex offender
registry? Text field
Have you served time in jail or prison? If so, list where and the year(s).Text field
Are you on probation or parole? If so, list the charge(s).Paragraph
Probation/Parole Officer Name Text field Probation/Parole Officer Phone Number Text field
Do you have any pending charges? If so, please list. Paragraph
Do you have any medical conditions? If so, list all conditions. Client health problems
Do you receive disability income? Text field What is the monthly amount Text field
If so, list your disability or disabilities.Paragraph
Do you have any health conditions that require care on your part or by health
professionals? If yes, please list the conditions and explain the care involved.
Client health problems
Do you currently take any medication? If so, list all medications you currently take.
Medication
Have you been treated at a psychiatric hospital for mental health issues, within the last
five years, for reasons other than alcohol or drug dependence? If so, list where and the
year(s) for each hospital.DateTreatmentCenterHistory
Have you been to treatment for alcohol or drug abuse? If yes, list where and the year(s)
for each. DateTreatmentCenterHistory
Have you been diagnosed with any psychological conditions other than drug and alcohol
dependency such as major depression, bi polar disorder, schizophrenia, paranoia,
border line personality, etc.? If yes, list all conditions. Text field Client diagnosis
Have you tried to commit suicide? If so, when? Text field
Are you an alcoholic? Text field
Date of last drink: Date
Are you an addict? Text field
Date of last use: Date List Drugs Used: Client substances of choice
I have answered all of the questions truthfully, accurately and completely.
Applicant Signature Signature Date Date
Applicant Printed NameText field Text field
Did someone assist you in completing this application? Text field If so, please provide their name and contact information here: Text field