Resident Application

Embark Recovery Housing

RESIDENT APPLICATION

 

APPLICANT INFORMATION

 

Today’s Date: 


Desired date to move into Embark Recovery Housing: 

Name: 
 

DOB:
SSN: 

Phone #: 
Email: 

Current physical address: 

Current mailing address (if different from physical):

Do you own or rent:

  Monthly payment:

How long:
What is your monthly gross income: 

Are you receiving welfare or other non-job-related income:

If yes, please explain:

Marital status: 

Married
Separated
Divorced
Widowed
Partnership
Single

Level of education completed: 

High School
College
Grad School
Other
Other: 

Are you a Veteran: 

Yes
No

Are you pregnant: 

Yes
No

Do you have a valid driver’s license: 

Yes
No

Do you have a car: 

Yes
No
  

Is it registered and insured:

Yes
No

Current Treatment Center: 

Expected discharge date: 

Who referred you to us: 

 

RECOVERY AND SUBSTANCE

 

Do you think you have a problem with alcohol: 

Yes
No
 

If yes, please explain: 

 

Do you think you have a problem with drugs: 

Yes
No

If yes, please explain: 

 

Primary addiction:

Date of last use:

List drugs/alcohol you used addictively: 
1st Route: 

Date of last use: 
   Age of 1st use:

2nd: Route: 

Date of last use:
   Age of 1st use:

3rd: Route: 

Date of last use: 
  Age of 1st use: 


EMERGENCY CONTACT

 

 

Name of person not residing with you: 


Relationship: 
Phone: 

Address: 


Name of person not residing with you: 


Relationship: 
  Phone: 

Address: 


Name of person not residing with you: 


Relationship: 
Phone: 

Address: 

 

OTHER INFORMATION

 

Please list hobbies and special interests:

What would you say your best characteristics are?

Do you have a medical Doctor: 

Yes
No

If yes, Name: 
  • Therapist Clinician #1

    doctor name:

    first visit:

    last visit :


Phone: 

 

EMPLOYMENT

Current employer: 


Address:
Phone:

Position: 

Current work schedule: (Show hours)
Sunday: 

Monday: 

Tuesday: 

Wednesday: 
 
Thursday: 

Friday: 

Saturday: 

 

List your last 3 employers:

Company Name: Supervisor: Contact Info:



 

 

 

If unemployed what are your plans for getting a job: 

Please list your vocational skills/specialized training or certifications:

LEGAL

 

Have you been arrested in the past 30 days: 

Yes
No

If yes, explain:

 

Are you currently on probation or parole: 

Yes
No

If yes: Probation Officer:

  Phone: 

Are you Mandated:

Yes
No

Are you experiencing legal problems (i.e. Court dates, warrants, active restraining orders): Please
describe: 

MEDICAL

 

So you take any prescription medications: 

Yes
No


Do you have any medical conditions or allergies: 

Yes
No

If yes, please explain:

When did you attend your last AA, NA, or recovery meeting: 

 

How many meetings have you attended in the last 30 days: 

Do you already have a sponsor or a Recovery Coach:

Yes
No
 
If yes, :  Name: 
Phone: 


Do you have any other recognized addictions or disorders (i.e. Eating disorder, cutting):

Yes
No

If yes, Please explain: 

How long have you been clean/Sober? 

What is the longest you have gone substance free?

How many previous recovery attempts/relapses have you had? 

Are you on any maintenance programs, and if so, which: 

Are you interested in being on a maintenance program? 

Have you ever lived in a home shared by other people:

Yes
No

Do you anticipate any problems with this:

Yes
No

If yes, Please explain? 

What is your main goal at this time? 

Please list anything else you feel is relevant to this application: 

I authorize the verification of the information provided on this form:
Signature: 


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