Applicant Information:
Today's Date:__________________________
_____________________________________________________________________________________________
Age Date of Birth
_____________________________________________________________________________________________
Last Name First Name Middle Initial
_____________________________________________________________________________________________
Current Address City State Zip
_____________________________________________________________________________________________
Home Phone Cell Phone E-mail address
_____________________________________________________________________________________________
Person to Contact in Emergency Relationship Phone #
_____________________________________________________________________________________________
Current Employer Supervisor’s Name
_____________________________________________________________________________________________
Employer’s Phone # Start Date Position
_____________________________________________________________________________________________
Monthly Wage Amount Other Income Source
Spouse/Significant Information:
_____________________________________________________________________________________________
Last Name First Name Middle Initial
_____________________________________________________________________________________________
Current Address City State Zip
_____________________________________________________________________________________________
Home Phone Cell Phone E-mail address
Parent Information: (If they are helping to support you)
_____________________________________________________________________________________________
Last Name First Name Middle Initial
_____________________________________________________________________________________________
Current Address City State Zip
_____________________________________________________________________________________________
Home Phone Cell Phone E-mail address
Vehicle Information: (The vehicle you will be parking at the property)
_____________________________________________________________________________________________
Make Model Year Color License Plate# State
Recovery Information:
1) Have you lived in a halfway or transitional living facility
before? No Yes
2) Have you ever been asked to leave a halfway house or transitional
living facility? No Yes
If yes, why? _________________________________________________________________________________
3) Are you currently in a treatment
facility? No Yes
If yes, which one? ____________________________________________________________________________
4) What is your drug/addiction of choice? ___________________________________________________________
5) How many times have you been in treatment for your addiction? ________________________________________
6) How long have you been sober? __________________________________________________________________
7 )What is your longest period of time of sober? ______________________________________________________
When?______________________
8) What is your religion if any? _____________________________________________________________________
9) Why do you want to live at this residence? _________________________________________________
Legal Information:
1) Have you ever had any legal problems? Yes No
If no, skip this section
2) Do you currently have any pending charges? Yes No
3) Do you have an upcoming court date? Yes No
If yes, when__________________________________________________________________________________
4) Are you currently on probation? Yes No
If yes, please provide the name and number of you probation
officer_____________________________________________________________________________________
5) Do you have any outstanding warrants for your arrest? Yes No
6) Do you currently have a case open with the Department of Children
and Families of Child Protective Services? Yes No
Medical/Psychiatric Information:
1) Do you have any medical condition(s)? (Asthma, Hepatitis, etc.) Yes No
If yes, what condition? _________________________________________________________________________
2) Do you have a physician to treat the above disorder? Yes No
If yes, name and phone number of physician:________________________________________________________
3) If you do not have a physician are you willing to obtain one? Yes No
What medications and dosages are you prescribed for the above condition(s)? _______________________________
_____________________________________________________________________________________________
4) Do you have any diagnosed psychiatric condition(s)?
(Depression, Bipolar, Panic Disorder, Eatinng Disorderetc.) Yes No