Embark Recovery Housing
RESIDENT APPLICATION
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:
Level of education completed:
Other:
Are you a Veteran:
Are you pregnant:
Do you have a valid driver’s license:
Do you have a car:
Is it registered and insured:
Current Treatment Center:
Expected discharge date:
Who referred you to us:
Do you think you have a problem with alcohol:
If yes, please explain:
Do you think you have a problem with drugs:
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:
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:
Please list hobbies and special interests:
What would you say your best characteristics are?
Do you have a medical Doctor:
If yes, Name:
Phone:
Current employer:
Address:
Phone:
Position:
Current work schedule: (Show hours)
Sunday:
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
List your last 3 employers:
If unemployed what are your plans for getting a job:
Please list your vocational skills/specialized training or certifications:
Have you been arrested in the past 30 days:
If yes, explain:
Are you currently on probation or parole:
If yes: Probation Officer:
Phone:
Are you Mandated:
Are you experiencing legal problems (i.e. Court dates, warrants, active restraining orders): Please
describe:
So you take any prescription medications:
Do you have any medical conditions or allergies:
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:
If yes, : Name:
Phone:
Do you have any other recognized addictions or disorders (i.e. Eating disorder, cutting):
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:
Do you anticipate any problems with this:
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:
Date: