Date
MM
DD
YYYY
Applicant's Name:
*
First Name
Last Name
Phone
*
(###)
###
####
Email
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of Birth:
*
Age:
*
Sex:
*
Marital Status:
*
Are you a Veteran?
*
Alcohol
Amount Used:
Cocaine
Amount Used:
Heroin/Opiates
Amount Used:
Marijuana
*
Amount Used:
Meth
*
Amount Used
Application filled out by:
*
Why do you want to stay in a sober living home now?
*
Are you currently using drugs or drinking alcohol?
*
What is your drug of choice?
*
How many years have you been using alcohol and drugs heavily?
*
Have you attempted to quit or cut down in the past?
*
How many times have you tried?
*
What is your longest period of sobriety?
*
Have you been in a drug or alcohol treatment program, or are you currently?
*
If so, where? When? Length of Stay? Clean Time?
Please be sure to answer all of the questions above
Are you currently depressed?
*
Do you have any of the following symptoms?
*
Please check all that apply
Are you currently suicidal?
*
Have you ever had suicidal thoughts?
*
Have you ever displayed violent behavior?
*
If Yes, please explain:
Have you ever had any homicidal thoughts?
*
Have you ever seen a psychiatrist or currently under the care of one now?
*
If yes, please identify the name of the doctor and the date of your last visit:
Have you ever been in any legal trouble?
*
If yes, please explain:
Do you currently have any pending legal charges?
*
If yes, please explain:
Have you ever been charged/convicted of domestic violence, assaults, or violent crimes?
*
If yes, please explain:
Have you ever been charged or convicted of any sex crimes?
*
If yes, please explain:
Are you currently on probation or parole?
*
If yes, who is your probation/parole officer?
What charges are you on probation/parole for?
Do you have any scheduled hearing dates?
*
If yes, please explain:
Have you been diagnosed with any of the following conditions?
*
Please check all that apply
Other Medical Concerns:
If answered yes to any concerns, have you been hospitalized for any of them?
*
If yes, please explain:
Do you have any disabilities, limitations, or special needs?
*
If yes, please explain:
Do you have a primary care physician?
*
If yes, what is their name and practice?
When was your last appointment?
Are you currently taking any medications?
*
If yes, please answer the questions below:
Name of medicine?
Dosage mgs?
Frequency?
Date last taken?
Reason for taking?
Are you allergic to any medications?
*
If yes, please explain:
Are you allergic to any foods?
*
If yes, please explain:
Are there any other medical concerns we should about? If yes, please explain:
*
What areas in your life would you like to work on while living here?
*
Are you currently in a romantic relationship?
*
If yes, please explain:
Do you have any children?
*
If yes, please list their names and ages:
Do you have visitation with them?
How is your relationship with your children?
Highest level of education?
Have you ever attended 12 step meetings before?
*
Are you willing to obtain a sponsor and work the 12 steps?
*
Do you currently have a local sponsor you are actively working with to improve your recovery?
*
Are you aware that Gateway Recovery Home is a faith-based recovery home?
*
Do you have an emergency contact person?
*
If yes, what is their name?
If yes, what is their address?
If yes, what is their phone number?
Do you have a second emergency contact person?
If so, please list their name, address, and phone number:
