Application for House Membership

Contact name and number to schedule a phone interview:Text field

Applicants Name: Client first name Client middle name Client last name

Date of Birth: Client birthdate 

Age: Text field

Phone: (c) Client phone

Email: Client email

In case of an emergency who do we contact: Contact

Home town:Client AddressClient CityClient State

Who referred you to MVDC Transition Home?Paragraph

What is your current source(s) of income? Paragraph

How much is your monthly income? Text field

What is your marital status:

 Client marital status

Do you have children? 

Radio buttons

If so, what are their names and ages: Paragraph

If you are under a physician’s care please list reason(s), name(s), and contact information? Paragraph


Any preexisting medical conditions? Client health problems

Allergies: Client allergies

Do you have any physical/emotional/mental limitations?

 Radio buttons

Are you taking any medications?

 Radio buttons

Please list medications and frequency: Medication

Do you have an advocate/social worker/case manager/therapist?


If so, list their name and contact information. Paragraph


Are you a veteran? 

Radio buttons

Client veteran status

Are you eligible for veterans benefits?

 Radio buttons

Have you been in contact with Veterans Affairs?

 Radio buttons

Are you in contact with a Veterans Service Officer? If so, Where? Text field

Is the Department of Children’s Services involved?

 Radio buttons

If so, what is the name and contact information of the DCF worker? Paragraph

Do you use alcohol or other drugs? 

Radio buttons

Sobriety Date:


Are you recovering from:


Do you struggle with other addictions or life controlling behaviors? 


If you answered yes to the question above, briefly describe how this impacts your life and if you have sought support in these areas. Paragraph

Have you been convicted of any felonies?

 Radio buttons

Have you ever been found guilty of a sexual offense?

 Radio buttons

Have you ever been convicted of arson? 

Radio buttons

Are you currently on probation?

 Radio buttons


Are you currently on parole? 

Radio buttons

Do you have health insurance?

 Radio buttons


Have you ever been in residential treatment?

 Radio buttons

If you are being released from a treatment program, please select from this list:


If you have been in treatment for substance use, either inpatient or outpatient within the last two years, give the name of each program (i.e. detox, treatment center, halfway house) the dates you attended, and the reason for leaving. (Type N/A if not applicable) 


Do you have a current mental health diagnosis?  If yes, please state what it is and how you are currently managing symptoms. ( Type N/A if not applicable) Paragraph

Client diagnosis

Are you a Christian?

 Radio buttons

If answered yes in being a Christian. When did you become a Christian? Date

Have you been baptized?


How has your faith impacted your recovery journey? Paragraph

Please describe any and all sources of income which you will use to pay rent: 


What other information would be helpful for us to know about you to serve you best? Paragraph


I acknowledge these rules.

Any house member may be asked to leave the Transition home for the following reasons:  

1.  Being in possession of, using, sharing, buying, or selling alcohol, unauthorized medication(s), or drug(s).

2.  Misusing prescribed or over-the-counter medication(s).

3.  Changing medication(s), dose amount, starting, or stopping medication(s) without prior authorization from Dr and MVDC Staff.

4. Allowing a person on the property who presents to be under the influence of drugs or alcohol.

5.  In non-compliance with the house standards, policies, or procedures.

6.  In noncompliance with drug and alcohol policy.

7.  In default of payment of rent fees.

8.  Has disruptive, disrespectful or hostile behavior towards house members & MVDC staff.

9.  Is verbally or physically abusive towards another house member  & MVDC staff.

10. Bullying or intimidation of house members & MVDC staff.

11. Causes damage or destruction of property.

12. Has lost focus of your recovery plan.

13. Involved in illegal activity or charged with a crime during house member at Transition home.

14. Stealing from another house member & MVDC staff. (this includes food).



I have read the above ATTENTION notice and understand that I am applying for membership at, MVDC's Transition home, as a member of a sober community. I agree to abide by MVDC’s principles and fully subject myself to MVDC’s standards, policies, procedures, and direction from MVDC's staff, and comply with the drug/alcohol policy of MVDC's transition home. I understand that I am subject to immediate expulsion if any of the preceding occur.


Print name: Text fieldText field