Somerset Sober Living Application 

Date: Date

Name: Client first nameClient last name

Date of Birth: Client birthdate

Phone Contact: Client phone

Sex: Client gender

Describe your current living situation: 


Drug of choice and last used when: 

Client substances of choice  Text field

How many years have you been using alcohol and/or drugs: Text field

Do you have any physical health/medical conditions or disabilities: 


Are you currently using any prescription medications? 


Do you have any previous felonies or misdemeanors. Please also list any ongoing legal issues: 


Are you able to be employed for at least 31 hours weekly, make recovery meetings, and participate in household chores: Text field