Sober Housing Resident Application
FreedomWorks Recovery Community Supportive Housing promotes safety, security, and sobriety for each of our residents. Our sober living environment provides our residents adequate structure and accountability with enough freedom to manage their own lives while complying with the expectations of the FreedomWorks Recovery Community.
Qualifications for our Sober Housing: Graduated long-term treatment, a minimum of 12 months track record of sobriety, employed for a minimum of 6 months at the same employer, able to provide first month and security deposit.
FreedomWorks staff will review the application materials. At the end of the review process, FreedomWorks staff will promptly send you a letter to advise you of their decision.
Date of Application Date Desired move-in date Date
Applicant Resident first name Resident middle name Resident last name SS# Text field
Date of Birth Resident birthdate Gender Resident gender (We are only able to provide housing for men at this time.)
Email Resident email Phone Resident phone Address Resident mailing address
Do you own your own vehicle? Dropdown Year/Make/Model Text field License Plate Number Text field
Do you have a valid drivers license? Dropdown State Text field License number Text field
Who referred you to us? Resident referred by
Have you ever been incarcerated? Dropdown When/How long?Text field ReasonText field
Are you currently on probation/parole? Dropdown Are you on Intensive Supervised Release? Dropdown
Have you ever been convicted of a sex offense? Dropdown
Do you have any current or pending charges? Dropdown If yes, please explain Paragraph
Please list any medication you are taking
Medication 1 name
Medication 2 name
Medication 3 name
Medication 4 name
Medication 5 name
Medication 6 name
Addiction type(s): Checkboxes Checkboxes Checkboxes Checkboxes Text field
What is your substance(s) of choice? Resident substance of choice
Date of last use: Resident sobriety date What was used? Text field
Past Treatment you have been in:
Name: Treatment center 1 name Did you successfully complete the program? Dropdown
Name: Treatment center 2 name Did you successfully complete the program? Dropdown
Do you attend 12-step Meetings? Dropdown How often? Text field Do you have a sponsor? Dropdown
Sponsors Name: Contact 3 name Phone number: Contact 3 phone Email: Contact 3 email
Have you lived in a Sober House before? Dropdown When/ how long? Text field
Name: Treatment center 3 name Location: Treatment center 3 notes Why did you leave? Paragraph
Are you employed? Dropdown
Employer (if yes): Resident current employment Location: Text field
Job Title: Resident occupation How long employed? Text field Current Monthly wage: Text field
2nd Employer: Text field Location:Text field
Job Title: Text field How long employment? Text field Current Monthly wage: Text field
Name: Contact 4 name Relationship: Contact 4 type Phone: Contact 4 phone
Name: Contact 5 name Relationship: Contact 5 type Phone: Contact 5 phone
Name: Contact 6 name Relationship: Contact 6 type Phone: Contact 6 phone
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.
I authorize FreedomWorks staff to contact my counselors, caseworker, parole offices, and any other supportive team member for additional information if needed.
Applicant SignatureSignature Date: Date
Release of Information Authorization
Applicant's Full name: Resident first name Resident middle name Resident last name
Date of Birth: Resident birthdate SSN: Text field
I (print name) Resident first name Resident middle name Resident last name authorize FreedomWorks staff the right to speak to individuals, referrals and/or agencies regarding my acceptance into FreedomWorks Sober Housing Recovery Community. I also authorize FreedomWorks staff to review and/or to receive mental health, physical health and probation/parole records upon request. I understand that:
- My health information is protected by Federal Confidentially Rules (42 CFR Part 2; and/or HIPAA, 45 CFR) and state privacy laws, and disclosure is allowed only with my authorization except in limited circumstances as outlined in FreedomWorks policies. I also understand that I have the right to inspect and receive a copy of my treatment records that may be disclosed to others as provided under applicable state and federal laws.
- I can revoke this authorization in writing at any time by providing a written notification to FreedomWorks, except to the extent that action has been taken in reliance on it.
- Communications resulting from this authorization will reveal that I have received or have attempted to receive accommodations at FreedomWorks’ Sober Housing Recovery Community.
- Federal confidentiality regulations prohibit disclosure of information.
- While living in the FreedomWorks Sober Housing Recovery Community. I cannot revoke the authorization release of information. I can, however, revoke this authorization upon leaving FreedomWorks.
Applicant Signature: Signature Date: Date
Office use only:
FreedomWorks Staff signature:______________________ Date:_____________
I chose to revoke this authorization
Participant signature: ____________________________ Date: ____________