Sober Living Application

Image

Date

Applicants Full Name

Best Contact Number

Client Email address

Date of Birth

Primary Insurance Name

Member Number

Group Number

Upload Insurance Card Front

Add file

Please upload a file

Upload Insurance Card Back

Add file

Please upload a file

Secondary Insurace

Policy Number

Group Number

Current Living Situation

Secondary Insurance Card Front

Add file

Please upload a file

Secondary Insurance Card Back

Add file

Please upload a file

Requested Move In Date

Gender

Male Female

Level of Education

Height

Weight

Hair Color

Race

Eye Color

Do you have identification?

Yes No

Do you have your insurance card?

Yes No

Do you own your own vehicle?

Yes No

Do you have a valid driver's license?

Yes No

Driver's License ID Number

State

Expiration Date

Make, Model, Year of Vehicle

License Plate Number

Car Insurance Carrier

Policy Number

Expiration Date

Proof of Car Insurance

If not on legal disabiity or retirement you will need to maintain full time employment to participate in our housing opportunity

Source of Income

Earnings per week

Employer Name

Employer Phone Number

Spouse or Significant Other's Name

Do you have children

Yes No

Do you have visitation with your children?

Yes No

Days and Frequency of Visitation with Children

Legal History

Have you ever been accused or convicted of a crime?

Yes No

If Yes Please explain and give dates

List any Pending Charges and County and State and include warrants

Are you a registered sex offender?

Yes No

Do you have a Probation/Parole officer or caseworker?

Yes No

PO/Caseworker’s Name:

Telephone #:

County, State

Emergency Contact

Emergency Contact Name

Emergency Contact Phone Number

Relationship

Address

City

State

Zip

Medical History

Are you currently under a doctor's care?

Yes No

What are you being treated for

Doctor's name

Organization

City

State

List all allergies

History of any of the following conditions?

Seizures

Yes

Date

Yes

Date

Diabetes

Yes

Date

Hepatitis

Yes

Date

HIV/AIDS

Yes

Date

Other

Mental Health

Have you ever been diagnosed with a mental health diagnosis?

Yes No

What are you diagnosis

Are you aware Roadways to Recovery is a Christian Sober Living Home

Yes No

Have you ever lived in a recovery house before?

Yes No

Date that you lived in sober living

If Yes, Name of Home?

Where was the home located

City

State

Why did you leave?

PROGRAM DISMISSAL AND REMOVAL FROM THE PROPERTY ACKNOWLEDGEMENT I understand that entrance into this program is voluntary and a privilege. This is not considered a residence but rather a program. In the event that any violation of the program rules or expectations could result in immediate dismissal from the program. I agree to adhere to the action of the program managers concerning dismissal. I agree that if asked to vacate the premises by management of Roadways to Recovery, I have a ONE (1) HOUR period to remove all personal items within the time allotted. If I refuse to vacate the premises or have not completely removed all personal items within the allotted time prescribed, I have been informed / agreed that you may be called to the premises to assist in my dismissal. It is also my full understanding that I will be allowed to re-enter this property only upon authorization from appointed staff. I understand that I have 5 days from the time of dismissal to remove my personal items from the property. If my items have not been removed, I understand that they will be donated at the staff's discretion. NOTICE: FAILURE TO COMPLY WITH THE TERMS OF THE PROGRAM DISMISSAL AND PERMANENT REMOVAL FROM THE PROPERTY COULD RESULT IN HARM OR DEATH TO YOURSELF OR OTHERS.

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