Embark Recovery Housing
RESIDENT APPLICATION
Today’s Date: Date
Desired date to move into Embark Recovery Housing: Date
Name: Client first name Client last name
DOB: Client birthdate SSN: SSN
Phone #: Client phone Email: Client email
Current physical address: Client Address
Current mailing address (if different from physical):Client Address
Do you own or rent:Dropdown Monthly payment:Text field
How long: Text field What is your monthly gross income: Text field
Are you receiving welfare or other non-job-related income:Text field
If yes, please explain:Paragraph
Marital status:
Checkboxes
Level of education completed:
Checkboxes Other: Text field
Are you a Veteran:
Checkboxes
Are you pregnant:
Checkboxes
Do you have a valid driver’s license:
Checkboxes
Do you have a car:
Checkboxes
Is it registered and insured:
Checkboxes
Current Treatment Center: Text field
Expected discharge date: Date
Who referred you to us: Text field
Do you think you have a problem with alcohol:
Checkboxes
If yes, please explain: Paragraph
Do you think you have a problem with drugs:
Checkboxes
If yes, please explain: Paragraph
Primary addiction: Text field Date of last use:Date
List drugs/alcohol you used addictively: Paragraph
1st Route: Text field
Date of last use: Date Age of 1st use:Text field
2nd: Route: Text field
Date of last use: Date Age of 1st use:Text field
3rd: Route: Text field
Date of last use: Date Age of 1st use: Text field
Name of person not residing with you: Text field
Relationship: Text field Phone: Text field
Address: Text field
Name of person not residing with you: Text field
Relationship: Text field Phone: Text field
Address: Text field
Name of person not residing with you: Text field
Relationship: Text field Phone: Text field
Address: Text field
Please list hobbies and special interests:
Paragraph
What would you say your best characteristics are?
Paragraph
Do you have a medical Doctor:
Checkboxes
If yes, Name: Therapist/Clinician Phone: Text field
Current employer: Text field
Address: Text field Phone:Text field
Position: Text field
Current work schedule: (Show hours)
Sunday: Text field
Monday: Text field
Tuesday: Text field
Wednesday: Text field
Thursday: Text field
Friday: Text field
Saturday: Text field
List your last 3 employers:
| Company Name: |
Supervisor: |
Contact Info: |
| Text field |
Text field |
Text field |
| Text field |
Text field |
Text field |
| Text field |
Text field |
Text field |
If unemployed what are your plans for getting a job:
Paragraph
Please list your vocational skills/specialized training or certifications:
Paragraph
Have you been arrested in the past 30 days:
Checkboxes
If yes, explain:Paragraph
Are you currently on probation or parole:
Checkboxes
If yes: Probation Officer:Text field Phone: Text field
Are you Mandated:
Checkboxes
Are you experiencing legal problems (i.e. Court dates, warrants, active restraining orders): Please
describe: Paragraph
So you take any prescription medications:
Checkboxes
Medication
Do you have any medical conditions or allergies:
Checkboxes
If yes, please explain:Paragraph
When did you attend your last AA, NA, or recovery meeting: Date Text field
How many meetings have you attended in the last 30 days: Text field
Do you already have a sponsor or a Recovery Coach:
Checkboxes
If yes, : Name: Text field Phone: Text field
Do you have any other recognized addictions or disorders (i.e. Eating disorder, cutting):
Checkboxes
If yes, Please explain: Paragraph
How long have you been clean/Sober? Text field
What is the longest you have gone substance free?Text field
How many previous recovery attempts/relapses have you had? Text field
Are you on any maintenance programs, and if so, which: Text field
Are you interested in being on a maintenance program? Text field
Have you ever lived in a home shared by other people:
Checkboxes
Do you anticipate any problems with this:
Checkboxes
If yes, Please explain? Paragraph
What is your main goal at this time? Text field
Please list anything else you feel is relevant to this application: Paragraph
I authorize the verification of the information provided on this form:
Signature: Signature Date: Date