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
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?
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?
Are you taking any medications?
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?
Client veteran status
Are you eligible for veterans benefits?
Have you been in contact with Veterans Affairs?
Are you in contact with a Veterans Service Officer? If so, Where? Text field
Is the Department of Children’s Services involved?
If so, what is the name and contact information of the DCF worker? Paragraph
Do you use alcohol or other drugs?
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?
Have you ever been found guilty of a sexual offense?
Have you ever been convicted of arson?
Are you currently on probation?
Are you currently on parole?
Do you have health insurance?
Have you ever been in residential treatment?
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
Are you a Christian?
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