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.

FreedomWorks staff will review the application materials. 

Date of Application Date  Desired move-in date Date                

Personal Information

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

 

Criminal History

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

Medical History

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

 

Your Recovery

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

Employment

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

 

Emergency Contact

      Name: Contact 4 name  Relationship: Contact 4 type  Phone: Contact 4 phone

References

      Name: Contact 5 name  Relationship: Contact 5 type  Phone: Contact 5 phone

      Name: Contact 6 name  Relationship: Contact 6 type  Phone: Contact 6 phone

Authorizations

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:

1. 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.
2. 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.
3. Communications resulting from this authorization will reveal that I have received or have attempted to receive accommodations at FreedomWorks’ Sober Housing Recovery Community.
4. Federal confidentiality regulations prohibit disclosure of information.
5. 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: ____________