To be accepted in an Unity House an applicant must complete this application and be interviewed by the residents of the particular Unity House to which the applicant is applying. The residents of the house then vote on acceptance. An 80% affirmative vote is needed to be accepted. Carefully read the application and honestly answer the questions. Living in an Unity House is special and if you understand its value it can help you achieve comfortable sobriety without relapse.

 

Name: Client first name Client last name 

City: Client City State: Client State Zip: Client Zip

Email: Client email Phone Number: Client phone

Work phone number where you can be reached: Text field

Birthdate: Client birthdate 

 

Are you currently at a treatment facility? 

Radio buttons

 

Are you an alcoholic? 

Radio buttons

Date of last drink?: Date

 

Are you addicted to drugs? 

Radio buttons

Date of last drug use?: Date

 

Do you want to stop drinking alcohol and using addictive drugs?

Radio buttons

List drugs you used addictively: 

Client substances of choice

other: Text field

 

Have you attended an AA or NA meeting?

Radio buttons

 

Are you employed? 

Radio buttons

Are you getting welfare or other non-job related income?

What is your monthly income? Employment 1 income

What do you expect your monthly income to be next month?: Text field

Marital Status: 

Client marital status

Do you have a medical doctor?

Have you ever been to a treatment facility for alcoholism and/or drug addiction?

Radio buttons

Do you take prescription drugs?

Radio buttons

Are you available to move in immediately?

Radio buttons

Contact information: 

Name: Contact 1 name Phone: Contact 1 phone

Type: Contact 1 type Email: Contact 1 email

How did you hear about our Home?

Paragraph

What did you hear about our Home?

Paragraph

Emergency contact: 

• [List family doctor, if you have one, + two family members or friends] Use the + to add rows.

Name: Contact 2 name Phone: Contact 2 phone

Type: Contact 2 type Email: Contact 2 email

Name: Contact 3 name Phone: Contact 3 phone

Type: Contact 3 type Email: Contact 3 email

Name: Contact 4 name Phone: Contact 4 phone

Type: Contact 4 type Email: Contact 4 email

Name: Contact 5 name Phone: Contact 5 phone

Type: Contact 5 type Email: Contact 5 email

 

I realize that the Unity House to which I am applying for has no tolerance for alcohol or drug use. I understand that if I am ever under the influence of alcohol or drugs, I am expelled immediately. In accepting these terms, the applicant excludes himself or herself from the normal due process afforded by local landlord-tenant laws.

 

Typing your name and date is used as a digital signature.

Name:  Client first name Client last name

Signature:

Signature

Date: Date

 

Use this space for additional relevant information:

Paragraph

 

 

I have read all of the material on this application form including the limitations set forth in item 26. I have also answered each question honestly and want to achieve comfortable recovery from alcoholism and/or drug addiction without relapse.

 

Typing your name and date is used as a digital signature.

Name:  Client first name Client last name

Signature:

Signature

Date: Client admit date

Facility: Client facility