Please complete to the best of your ability. Giving complete and honest answers allow us to serve you the best.

Today's Date: Date   Requested Move-in Date: Date

Print Name: Client first nameClient middle nameClient last name

Preferred Name/Nickname: Client nickname

Current Address:

Client AddressClient CityClient StateClient Zip

Date of Birth:Client birthdate

Phone:Client phone

Alternative Contact Phone:Client phone

Email:Client email

 

Substance History

 

Are you an Alcoholic?

Radio buttons

Date of Last Drink? Text field

Are you addicted to Drugs?

Radio buttons

Date of last drug use? Text field

List drug(s) of choice: Client substances of choice

Date of last AA/NA Meeting? Text field

Number of AA/NA meetings you attend weekly? Number field

Do you have an AA/NA home group?

Radio buttons

Do you have a sponsor? Client sponsor

If so, what is their name? Text field

 

Employment History

 

Are you currently Employed? 

Radio buttons

If yes, name and location of Employer: Text field

How long have you worked there? Text field

What is your pay rate?Text field

Briefly describe plans for employment once you arrive. If you cannot work 40 hours per week, please explain why.

Text field

Current Monthly Income:Number field

How do you plan on covering first month's rent? Text field

Do you receive any non-job related financial support?

Checkboxes

 

Social History

 

Marital Status: Client marital status

Are you a Veteran? Client veteran status

How do you identify? Client race

Native Nation/Tribal Affiliation, if any: Text field

What legal programs are you involved in?

Checkboxes

 

Medical/Psychiatric History

Do you have a doctor or any other medical professional?

Radio buttons

If so, please list name and type of medical professional. Text field

List any and all medical or psychiatric diagnoses:

Client diagnosisClient health problems

Are you pregnant?

Radio buttons

Do you take any prescription medication?

Radio buttons

List all medications currently prescribed:Text field

Are you enrolled with or receiving services from a behavioral health facility?

Radio buttons

If yes, include the name of the facility and contact person: Text field

Have you completed a 28 day or longer residential program?

Radio buttons

If yes, where and when? Text field

Do you currently see a counselor/therapist?

Radio buttons

If yes, provide name: Text field

Have you lived in a sober living environment before? Did you leave voluntarily? Were you expelled? Please explain. Your answer will not be grounds for denial. 

Text field

 

Emergency Contacts

 

Please provide two emergency contacts with their phone numbers and relationship to you. They will only be contacted in an emergency.

Emergency contact #1

Name:                     Text field

Phone Number:        Text field

Relationship to you:  Text field

 

Emergency contact #2

Name:                    Text field 

Phone Number:       Text field

Relationship to you: Text field

 

I understand that Mountain Recovery Alliance has been established to promote recovery from alcoholism and/or drug addiction. All residents are prohibited from using any alcohol or mind-altering drugs; and anyone who engages in using mind-altering drugs or alcohol risks being expelled from the program. In accepting these terms, the applicant understands that these conditions are different than the normal due process afforded by local landlord-tenant laws and does not in any way constitute a landlord/tenant relationship.

I have read all of the material on this application form and have answered each question honestly and to the best of my ability, and want to achieve recovery from alcohol and/or drug addiction.

Signature:Signature