Application

Application for Residence - Next Step Sober Living

A Faith Based Sober Living Environment for Men

We are currently accepting applications from men aged 21+. Anyone applying to live in the house must read the Residents Guidelines and submit this completed application prior to interviewing, and must be clean & sober 30 days or successfully complete a residential treatment program. A deposit of $75.00 is required for the interview process and first week payment due at time of move in. The deposit will be deducted from the payment (money order or credit/debit card only).

PERSONAL INFORMATION PLEASE PRINT CLEARLY

Full Name_______________________________________DOB_________ Age ____

Phone____________________________Email_________________________________

Last four of Social Security #________________________ Marital Status_____________

Current Living Situation ___________________________________________

Current Address________________________ City_____________ State_____ Zip_____

Valid Driver License? Yes No

State Driver License # ___________________

Own a vehicle? Yes No

Year/Make/Model License # _______________________________________

RECOVERY INFORMATION

Are you an alcoholic? Yes No Drug addict? Yes No Drug(s) of Choice ______________

Date of Last Use________________________

Currently/recently in treatment? Yes No

Name & Location of Facility ____________________________________________

Did you complete successfully? Yes No

Discharge Date________________ Name of Counselor______________________

How do you plan to stay clean and sober? __________________________________________________

Who referred you to Next Step Sober? _____________________________________________________

Name, Relationship & Phone of reference __________________________________________________

Do you attend 12-step meetings? Yes No

If so, how often? _____________Do you have a sponsor? Yes No

Name and number of sponsor ___________________________________________

Have you lived in a recovery house before? Yes No

Name & Location of House _____________________________________________

When/How long?_____________ Why did you leave there? ____________________________________

Why do you want to live at Next Step Sober Living? ___________________________________________

EMPLOYMENT INFORMATION

Are you employed? Yes No

If Yes, Name & Location of Employer

Job Title__________________________ How long employed?

Current Monthly Income ______________________________________________

What other types of work have you done? ________________________________

Special Skills/Training ____________________________________________

If No, How long since last employed? ____________________________________

Are you willing/able to get a job within 30 days? Yes No

Are you willing/able to be self-supporting? Yes No

Will someone else be helping you pay rent or deposit? Yes No

Name/Relationship________________________________________ Phone __________

Address Street_____________________ City__________________ State____ Zip _____

LEGAL INFORMATION

List Pending Charges/Cases/Warrants _________________________________________

Ever been incarcerated? Yes No

When/How Long?______________________________________________________

Reason_______________________________________________

Name & Location of Facility _______________________________________________

Currently on probation/parole? Yes No

Location of Office __________________________________________

Name of Officer___________________________________ Contact Phone__________

Are you a registered sex offender? Yes No

List Felony Convictions __________________________________________________________________________________________________________________________________________________________________________________________________________________

MEDICAL INFORMATION

List All Medical/ Psychiatric Conditions______________________________________________________

List All Current Medications ______________________________________________________________

Describe Any Injuries/Disabilities __________________________________________________________

Describe Physical Limitations Resulting from Disabilities________________________________________

Name of Physician____________________________________________

Are you receiving Suboxone, Subutex, Methadone, Vivitrol, etc? Yes No

Physician Prescribing__________________________________________

EMERGENCY CONTACTS (LIST TWO)

Name_______________________________ Relationship_________________________ Phone________

Street__________________________ City___________________ State____ Zip _____

Name__________________________ Relationship__________________ Phone______

Street_________________________ City______________________ State____ Zip ____

I have read and agree to all house rules, and I swear every word of this application is true.

Sign Name____________________________________________ Date_____________