Recovery House Application – SpiritLife Inc.

Legal Name:

First

Last

Primary Email Address

Email

Confirm Email

This is required for our Recovery House Manager to get in touch with you.

Current Age:

Phone Number:

Expected Arrival Date?

Format: MMDDYYYY (No spaces, dashes, or other symbols.

How do you plan to pay your 1st months rent?

When will you be able to make your 1st months rent payment?

Format: MMDDYYYY (No spaces, dashes, or other symbols.

Emergency Contact Name:

First

Last

Emergency Contact Phone:

Emergency Contact's relationship to you:

Emergency Contact's address:

Why would you like to be in our Sober/Recovery house?

Please list any previous treatment programs you have participated in:

If no previous history, please enter “no history”.

History of previous Psychiatric Hospitalizations?

Yes
No

If yes, please explain where you received treatment, when, and reasoning for treatment.

If no previous Psychiatric Hospitalization history, skip this field.

Do you have any current suicidal or homicidal ideations?

Yes
No

Have you ever been diagnosed with PTSD?

Yes
No

Have you ever had a previous attempt at suicide?

Yes
No

of to show

If yes, please explain when the last attempt was and the method:

Format: MMDDYYYY (No spaces, dashes, or other symbols. If no history of suicide attempts exist, skip this field.

Do you have any Mental Health diagnoses?

If no MH history exists, please skip this field.

Do you currently have any Medical Conditions?

If no Medical Conditions exist, please skip this field.

Please list all medications that you are prescribed:

If you have no medications, you must enter “no medications”. If medications are listed, please include the name, strength, and dosing frequency.

Are you able to walk up and down three flights of stairs on your own without assistive devices?

Yes
No

Current IOP or Non-Intensive OP treatment location:

You must have IOP or evaluation set up for the first week after you arrive. If you currently do not have one, please list “I don’t have one.”

What is your substance of choice? (Select all that apply)

What is your abstinence date? (Clean date)

Format: MMDDYYYY (No spaces, dashes, or other symbols.

Please list your Home Group and Sponsor's name:

First

Last

Marital Status

Significant Other's Name (If applicable):

First

Last

Will there be children coming to visit you?

Yes
No

If yes, please list the names, ages, and expected visitation times of the children that will be coming to visit.

Please list your most recent work history. Include your last employer as well as their address and phone number.

Which kind of identification do you have currently?

Is the ID listed above active?

Yes
No
I do not currently have ID.

Do you have any of the following current/open legal issues? Select all that apply.

If you have listed probation or parole above, please list your officer's name, phone number, and county.

Have you ever been convicted of a sex crime?

Yes
No

Have you ever been convicted of Assault and/or Battery?

Yes
No

Have you been administratively discharged or evicted from any treatment facility or recovery house within the past 30 days?

Yes
No

Are you willing to go to 90 meetings in 90 days?

Yes
No

Are you willing to follow all house rules?

Yes
No

Personal Reference #1

First

Last

Personal Reference #2

First

Last

Do you understand you will be subject to random drug testing?

Yes
No

Do you understand that if you are asked to leave the 3/4 house; you have approximately 1 hour to remove all of your personal belongings and vacate the premises?

Yes
No

Please type your full name to show agreement with the above statement:

First

Middle

Last

By entering your First Name, Middle Initial, and Last Name in the fields provided, you certify that this entry constitutes your digital signature on this application for SpiritLife’s ¾ Recovery House. You acknowledge that this digital signature is legally binding and affirms that the information provided in this application is accurate to the best of your knowledge.

You certify that you have given true and accurate information about your medical and legal status and given circumstances. You also understand that any false information provided to the Recovery 3/4 House may result in this application being denied, or the loss of the bed; once the falsified information is verified as such.

By entering your initials in the field provided, you certify that this entry serves as your digital initials on this application for SpiritLife’s ¾ Recovery House. You understand that these digital initials confirm your agreement to the information disclosed and affirm its accuracy.