What location are you applying for?
*
Gender
*
Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Age
*
When would you like to move in?
*
Phone Number
*
(###)
###
####
Email
*
Current Living Situation
*
Current Address
If Applicable
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Do you own a vehicle?
*
Yes
No
Vehicle Year / Make / Model
License Plate Number
Valid Driver's License?
*
Yes
No
Driver's License Number
Vehicle Insurance Policy Number
Do you have children?
*
If so, please list ages of children and what the custody agreement is.
Have you ever been addicted to alcohol?
*
Have you ever been addicted to drugs?
*
Date of Last Use
*
Drug(s) of Choice
*
Currently/recently in treatment?
*
Did you complete successfully?
*
Past or Upcoming Discharge Date
MM
DD
YYYY
Counselor Name
How do you plan on staying clean and sober?
*
Please describe your current recovery program, meeting attendance, sponsorship, etc.
Who referred you to Common Ground Sober Residences?
*
Do you attend 12-step meetings?
*
If so, how often?
Do you have a sponsor?
*
Have you lived in a sober house before?
*
List previous sober homes
*
Include name and location of the house, how long you lived there, and why you left.
Why do you want to live at Common Ground sober residences?
*
Are you employed?
*
If yes, list the name and location of your employer.
Job Title
How long have you been employed?
If you are not employed, how long since you were last employed?
Are you willing and able to get a job within 30 days?
*
Are you willing and able to be self-supporting?
*
Please list any pending charges / cases / warrants that you are aware of.
*
If none, please write "none."
Are you currently on probation or parole?
*
County of Probation
Name of Probation Officer
Probation Officer Phone Number
(###)
###
####
Are you a registered sex offender?
*
List felony convictions
*
List all medical/psychiatric conditions
*
If none, please write "none."
List all current medications
*
If none, please write "none."
Describe any injuries/disabilities.
Describe any physical limitations resulting from disabilities.
Name of Physician
Are you receiving Suboxone, Subutex, Methadone, Vivitrol, etc.?
*
Physician Prescribing
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Relationship
*
Emergency Contact Phone Number
*
(###)
###
####
Emergency Contact Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of Application
*
MM
DD
YYYY
