TRANSITIONS MEMBERSHIP APPLICATION
APPLICATION PROCESS:
1. COMPLETE APPLICATION
2. SIGNING OF THE CLIENT EXPECTATIONS AND CONTRACT
3. IF ACCEPTED, ARRANGE TIME AND DATE OF ARRIVAL
Please note: An acceptance letter will be issued only after the completion of the above process.
This application is for internal uses only. The questions are designed to assist Transitions Sober Living in utilizing our resources to assist you in your recovery through accountability and aiding you in any obstacles you may need to overcome.
Name: Client first name Resident middle name Resident last name
Home Address: Resident mailing address
Cell Phone: Resident phone
Home Phone: Text field
Email: Resident email
Emergency Contact Name: Contact 1 name
Relation:Contact 1 type
Address:Text field
Phone Number: Contact 1 phone
Email: Contact 1 email
Driver’s License Number: Text field State: Text field
Or
ID Card Number:Text field State:Text field
Social Security Number: Text field
Transportation:
Checkboxes
Vehicle Year & Manufacturer:Text field
Model:Text field Color: Text field
Marital status: Resident marital status
Children
Radio buttons
Are you getting SSI, Disability or other non-job related income?
Radio buttons
Who will be financial responsible for your program fee?
Checkboxes
Are you currently enrolled in a form of higher education?
Radio buttons
If Yes:
Name of Institution:Resident school
Are you employed?
Radio buttons
If Yes:
Name of employer: Resident current employment
Contact Number (w/ extenstion if applicable): Contact 2 phone
Are you a recovering Alcoholic:
Radio buttons
Recovering drug addict:
Radio buttons
Sobriety date:Resident sobriety date
List drugs (including alcohol) you used addictively: Resident substance of choice
Are you discharging from a substance abuse treatment program, either inpatient or outpatient?
Radio buttons
If Yes - Facility Name: Treatment center 1 name
Counselor: Contact 3 name
Phone Number: Contact 3 phone
Email Address:Contact 3 email
Discharge Date: Treatment center 1 ended
If No: Current Living Location: Paragraph
Phone Number: Text fieldExt: Text field
Move in Date:Date
Are you planning to attend an aftercare program or an intensive outpatient program?
Radio buttons
If Yes: Name of Aftercare Provider or IOP:Resident IOP
If No: Do you plan to attend at least 4 meetings per week?
Radio buttons
Do you have a sponsor?
Radio buttons
If Yes: Name of Sponsor:Contact 4 name
Phone Number:Contact 4 phone
If No: How soon do you expect to obtain a sponsor? Date
Are you participating in or about to enter medication assisted therapy?
Radio buttons
Do you have any problems with sleeping (snoring, sleep apnea, sleep walking, insomnia, etc...)?
If Yes, which ones?Text field
Do you take prescription drugs?
Radio buttons
If yes, list drug name and prescribing doctor Reason & Frequency of Doses:
Medication #1
Medication: Medication 1 name Dosage: Medication 1 dosage
Quantity: Medication 1 quantity Category: Medication 1 category
Frequency: Medication 1 frequency MD: Medication 1 md
Notes: Medication 1 notes
Medication #2
Medication: Medication 2 name Dosage: Medication 2 dosage
Quantity: Medication 2 quantity Category: Medication 2 category
Frequency: Medication 2 frequency MD: Medication 2 md
Notes: Medication 2 notes
Medication #3
Medication: Medication 3 name Dosage: Medication 3 dosage
Quantity: Medication 3 quantity Category: Medication 3 category
Frequency: Medication 3 frequency MD: Medication 3 md
Notes: Medication 3 notes
Medication #4
Medication: Medication 4 name Dosage: Medication 4 dosage
Quantity: Medication 4 quantity Category: Medication 4 category
Frequency: Medication 4 frequency MD: Medication 4 md
Notes: Medication 4 notes
Medication #5
Medication: Medication 5 name Dosage: Medication 5 dosage
Quantity: Medication 5 quantity Category: Medication 5 category
Frequency: Medication 5 frequency MD: Medication 5 md
Notes: Medication 5 notes
Medication #6
Medication: Medication 6 name Dosage: Medication 6 dosage
Quantity: Medication 6 quantity Category: Medication 6 category
Frequency: Medication 6 frequency MD: Medication 6 md
Notes: Medication 6 notes
Medication #7
Medication: Medication 7 name Dosage: Medication 7 dosage
Quantity: Medication 7 quantity Category: Medication 7 category
Frequency: Medication 7 frequency MD: Medication 7 md
Notes: Medication 7 notes
Medication #8
Medication: Medication 8 name Dosage: Medication 8 dosage
Quantity: Medication 8 quantity Category: Medication 8 category
Frequency: Medication 8 frequency MD: Medication 8 md
Notes: Medication 8 notes
Medication #9
Medication: Medication 9 name Dosage: Medication 9 dosage
Quantity: Medication 9 quantity Category: Medication 9 category
Frequency: Medication 9 frequency MD: Medication 9 md
Notes: Medication 9 notes
Medication #10
Medication: Medication 10 name Dosage: Medication 10 dosage
Quantity: Medication 10 quantity Category: Medication 10 category
Frequency: Medication 10 frequency MD: Medication 10 md
Notes: Medication 10 notes
Do you have any current court case pending, other than moving violations?
Radio buttons
Have you ever been convicted of a felony?
Radio buttons
If Yes:
Violation:Text field
Please select:
Radio buttons
County:Text field City: Text fieldState:Text field
If Yes, Explain:
Paragraph
Have you ever lived in a sober house before?
If Yes, which ones?Text field
How did you hear about Transitions Sober Living (Referral, Web-site, Internet Search, Treatment Facility,
etc..)?Text field
By signing the application below, I authorize Transitions Sober Living to utilize the above information to process my request for membership.
Name of Applicant (Please print):Resident first name Resident last name
Signature of Applicant:Signature
Date: Date