1. Shoreline Recovery Application

Shoreline Recovery Application



First Name: Client first name

Middle Name: Client middle name

Last Name: Client last name

Driver’s License (state & number): Text field

Email: Client email

Mobile Number: Client phone

Date of Birth: Client birthdate

Age: Text field

Marital status: Client marital status



If yes, how many and what are their ages? Text field

Gender: Client genderTreatment center 1 started

Veteran: Client veteran status


Treatment Experience


Are you currently in treatment?

If yes, where? Treatment center 1 name

Type of program:Treatment center 1 type

Clinician Name: Treatment center 1 notes

Clinician email address: Treatment center 1 address

Clinician telephone number: Treatment center 1 name


Admission date: Treatment center 1 started

Expected discharge date:Treatment center 1 ended





Sobriety/Clean Date: Recovery history 1 sobriety date

List Alcohol & Drugs of Abuse: Client substances of choice

If admitted, what is your requested move-in date to a Shoreline Recovery home: Client admit date

Please tell us about your recovery history (to include past successes and obstacles to maintain sobriety):

Text field


Sober Living Experience


Have you ever lived in a sober house before?: 


Name of Sober House: SoberLivingHistory



Emergency Contact Information:


Contact #1

Name: Contact 1 name

Phone: Contact 1 phone

Contact 1 type

Email Address: Contact 1 email


Contact #2

Name: Contact 2 name

Phone: Contact 2 phone

Contact 2 type

Email Address: Contact 2 email



List of Current Medications: 


List Psychiatric Medications First

Medication #1 Medication 1 name

Medication #2 Medication 2 name

Medication #3 Medication 3 name

Medication #4 Medication 4 name

Medication #5 Medication 5 name

Medication #6 Medication 6 name

Other Medications: Medication 7 name




If so, what are you allergic to? Client allergies




Employment & Education

Are you employed? 


If yes, who is your employer? Text field

If not, what job plans do you have? Text field

What is your monthly income right now? Employment 1 income

Are you in School: 


Highest level of education completed: Dropdown




Do you currently have any pending legal cases?


If Yes, what are you charged with? Text field


Are you currently on probation or parole? 


If Yes, what are you convicted of? Text field


Have you ever been convicted of a felony? 


If yes, what were you convicted of, and in what year did the conviction occur? Text field


Are you currently on the sex offender registry? 





Medical & Psychiatric


Do you have a medical doctor? 


If yes, Text field

Name: Text field

Telephone Number:Text field


Current medical conditions? 

Text field


Do you have a mental health medication prescriber? 


If yes, Text field

Name:Text field

Telephone Number:Text field


Do you have a mental health counselor? Checkboxes

If yes, Text field

Name:Text field

Telephone Number: Text field


Psychiatric History:

Have you been diagnosed with or treated for:

Bipolar disorder 




Post-traumatic stress 








Psychosis NOS


Obsessive-Compulsive Disorder (OCD)


Alcohol abuse 




Substance abuse 


Suicide attempt


Interpersonal Violence 


Eating Disorder 




In order to move into a Shoreline recovery residence you must be vaccinated and boosted or willing to get vaccinated within one day of moving in.

Have you been vaccinated against COVID? Checkboxes

If yes, what are the dates of your vaccinations Date  Date Boosters? Date  Date

If you haven't received the booster, you will be required to do so to live at Shoreline.

Statement of Perjury

It is important that the information you give us is true and that you understand what happens if you are not giving truthful information on this form. You may be punished by fine or imprisonment or both (18 U.S.C. 1001). To indicate you have read and understand the above, please certify below:

I, Text field, hereby certify that the answers I provided above are truthful. 

Text field (Signature) Date (Today’s date)



Medical Insurance


Insurance Provider: Client insurance provider

Group ID: Client insurance group ID

Policy Number: Client insurance policy #

Primary on Insurance: Client insurance other


Residential Fees


Who will be responsible for paying your residential fees and living expenses if you are accepted into Shoreline Recovery?

Name: Contact 3 name    

Relationship: Text field

Telephone: Contact 3 phone

Email Address: Contact 3 email





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.

Resident Signature: Signature

Date: Date