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House Member
Application

Personnel Information

Do you currently live in a safe, housed environment?
Yes
No
Have you ever lived in a sober living environment before?
Yes
No

Emergency Contact

Do you have an emergency contact?
Yes
No

Recovery History

Have you ever attended or attending a recovery treatment program (IOP, PHP, Residential)?
Yes
No
Are you currently attending any support groups (e.g., AA, NA)?
Yes
No
Do you have any diagnosed medical conditions?
Yes
No
Are you currently prescribed any medications?
Yes
No
Are you currently on probation or parole?
Yes
No
Are you required to register as a sex offender?
Yes
No

Employment

Financial Status

Confirmation

I agree to abide by the rules and regulations of the sober living residence.
Yes
No
I understand that failure to comply may result in termination from the program.
Yes
No
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