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Apply for Residency
(Strictly Confidential)
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Name
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First
Last
Alias
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Birthdate
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Phone Number
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Email
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Employer, if applicable
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Drug(s) of Choice (Alcohol, Opiates, Etcetera)
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Do You Have Funds Available for Rent?
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No
Yes
Sobriety Date
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Have You Stayed In a Sober Living Location in the Past?
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No
Yes
How Long Was Your Last Stay in Sober Living?
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Where are you staying now?
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Do you have a significant other (IE: wife or girlfriend)?:
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Yes
No
Number of Past Drug Overdoses
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Last Overdose Date
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Number of Times in Treatment
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Most Recent Inpatient Location?
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Most Recent Psych Hospital Location
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Do You Have Any Allergies?
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No
Yes
If So, Please List
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Are You In Mental Health Treatment?
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No
Yes
Please List Any Medical Health Diagnosis
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Do You Suffer From any Specialized Health Conditions Such as Diabetes or Seizures? If So, Please List
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List of All Current Prescribed, Over the Counter Medications & Supplements
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Current or Pending Legal Charges?
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No
Yes
If Yes, Please Explain:
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Open Warrants?
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No
Yes
In What County or Jurisdiction?
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Sex Offender?
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No
Yes
If Yes, What Level?
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Domestic Violence Charges?
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No
Yes
Are You on Probation/ Parole?
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No
Yes
What County/ Jurisdiction?
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Probation/ Parole Officer Name:
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Officer Phone Number:
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Please Feel Free to Add Additional Comments, Concerns or Questions in the Following Box:
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Submit
About Us
Amenities
Testimonials
Application