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
Radio buttons
What is your monthly income? Employment 1 income
Marital Status:
Client marital status
Radio buttons
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
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What did you hear about our Home?
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Emergency contact:
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
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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