[Your Name]Client first nameClient last name

[Your Address] Client Address

[City, State, ZIP Code] Client CityClient StateClient Zip

[Phone Number] Client phone

[Email Address] Client email

[Date] Date

 

Wings of Hope Sober Recovery Facility

 

 

Dear Admissions Committee,

 

I am writing to express my strong desire to become a member at Wings of Hope Sober Recovery. I am committed to maintaining my sobriety and creating a healthy and supportive environment for myself, and I believe that Wings of Hope Sober Recovery can provide the structure and community I need to achieve these goals.

 

Personal Information:

 

Full Name: Text field

Date of Birth: Client birthdate

Gender: Client pronoun

Emergency Contact Name: 

Contact

 

Criminal History: 

Have you ever been convicted of a crime? (If yes, please provide details):

Paragraph

Sobriety Information:

 

How long have you been sober? Text field

Do you have a sponsor or recovery support system? Client sponsor

Will you be able to submit a negative urinalysis (drug screen) upon entry into the program? Dropdown

 

Family and Friend References:

 

Name: Text field Relationship: Text field

Phone: Text field Email: Text field

 

Employment History:

 

Are you currently employed? Text field

Current/Most Recent Employer: Text field

Position: Text field Dates of Employment:Date

Reason for Leaving: Paragraph

 

 

Living History:

 

Current Address: Text field

 

 

 

Medications:

 

List all medications you are currently taking (prescription and over-the-counter):

Medication

 

Medical Information:

 

Primary Care Physician's Name: Text field

Primary Care Physician's Contact:Text field

Medical Diagnosis/History: Text field

Allergies: Text field

 

Addiction History:

 

Please provide a brief overview of your history with addiction, including substances used and any prior treatment attempts:Client substances of choice

 

Meetings Attending:

 

List any recovery meetings or support groups you are currently attending:Client kinds of meetings attended

 

Mental Health History:

 

Briefly describe any history of mental health issues or diagnoses:Client diagnosis

 

 

Transportation:

 

Do you have reliable transportation? Radio buttons If yes, please provide details:Paragraph

 

How long do you plan on staying with us? Paragraph

 

How did you hear about us? Dropdown

 

Who are you being reffered by? 

Name of Person (If self leave blank):Text field

Name of Agency (If self leave blank):Text field

How soon are you looking to join the Wings of Hope Family and become a member? Paragraph

Would you like to be prioritized for our brand new men's house, opening in May 2025: Checkboxes

 

I understand that my application will be reviewed and that admission into Wings Of Hope is not guaranteed. I am fully committed to abiding by the rules and guidelines of the sober home, participating actively in the community, and maintaining my sobriety.

I understand that I am required to provide truthful, complete, and accurate information throughout the intake and admissions process. I acknowledge that any false, misleading, or incomplete information I provide—whether spoken or written—may result in denial of admission or immediate dismissal from the program.

Thank you for considering my application. I look forward to the possibility of joining the Wings Of Hope

community and embarking on this transformative journey. Please feel free to contact me at 860-222-2768 or business@wingsofhoperecovery.com if you have any questions or require additional information.

 

Sincerely,

 

[Your Signature]SignatureDate

 

[Your Printed Name]Text field

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.