Wings Of Hope Application/ Intake Form

[Your Name]

[Your Address] 

[City, State, ZIP Code] 

[Phone Number] 

[Email Address] 

[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: 

Date of Birth: 

Gender: 

Emergency Contact Name: 


 

Criminal History: 

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

Sobriety Information:

 

How long have you been sober? 

Do you have a sponsor or recovery support system? 

 

 

Family and Friend References:

 

Name:  Relationship: 

Phone:  Email: 

 

Employment History:

 

Are you currently employed? 

Current/Most Recent Employer: 

Position:  Dates of Employment:

Reason for Leaving: 

 

 

Living History:

 

Current Address: 

 

 

 

Medications:

 

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


 

Medical Information:

 

Primary Care Physician's Name: 

Primary Care Physician's Contact:

 

Addiction History:

 

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

Don't see the option you're looking for? Click here

 

Meetings Attending:

 

List any recovery meetings or support groups you are currently attending:

Don't see the option you're looking for? Click here

 

Mental Health History:

 

Briefly describe any history of mental health issues or diagnoses:

Don't see the option you're looking for? Click here

 

 

Transportation:

 

Do you have reliable transportation?

If yes, please provide details:

 

How long do you plan on staying with us? 

 

How did you hear about us? 

 

Who are you being reffered by? 

Name of Person (If self leave blank):

Name of Agency (If self leave blank):

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

Would you like to be prioritized for our brand new property, opening in February 2025: 

 

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.

 

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 (203)646-7156 or robert@traveloproperties.com if you have any questions or require additional information.

 

Sincerely,

 

[Your Signature]


 

[Your Printed Name]

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.

 

 

 

SunMonTueWedThuFriSat
2930311234567891011121314151617181920212223242526272829303112345678
SunMonTueWedThuFriSat
2930311234567891011121314151617181920212223242526272829303112345678
SunMonTueWedThuFriSat
2930311234567891011121314151617181920212223242526272829303112345678
SunMonTueWedThuFriSat
2930311234567891011121314151617181920212223242526272829303112345678
SunMonTueWedThuFriSat
2930311234567891011121314151617181920212223242526272829303112345678
SunMonTueWedThuFriSat
2930311234567891011121314151617181920212223242526272829303112345678