Resident Application

Embark Recovery Housing

RESIDENT APPLICATION

 

APPLICANT INFORMATION

 

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: 

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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: 

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Is it registered and insured:

Checkboxes

Current Treatment Center: Text field

Expected discharge date: Date

Who referred you to us: Text field

 

RECOVERY AND SUBSTANCE

 

Do you think you have a problem with alcohol: 

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If yes, please explain: Paragraph

 

Do you think you have a problem with drugs: 

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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

EMERGENCY CONTACT

 

 

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

 

OTHER INFORMATION

 

Please list hobbies and special interests:

Paragraph

What would you say your best characteristics are?

Paragraph

Do you have a medical Doctor: 

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If yes, Name: Therapist/Clinician Phone: Text field

 

EMPLOYMENT

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

LEGAL

 

Have you been arrested in the past 30 days: 

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If yes, explain:Paragraph

 

Are you currently on probation or parole: 

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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

MEDICAL

 

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