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Residency Application
Residency Application
(all information is kept confidential)
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Indicates required field
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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Do You Have Funds Available for Rent?
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No
Yes
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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Please List the Names of All Your Previous Housing Locations. (Last First)
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Please List All Your Reasons for Leaving Locations in the Past:
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Do you have a significant other (IE: wife or girlfriend)?:
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Yes
No
Number of Children?
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State ID #
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State of Identification
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Ohio
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming
Active Insurance?
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No
Yes
If Yes, With Whom?
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Sobriety Date
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Drug(s) of Choice (Alcohol, Opiates, Etcetera)
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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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When Was This Inpatient Treatment?
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Number of Psych Hospitalizations
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Most Recent Psych Hospital Location
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When Was This Psych Hospitalization?
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Currently In Treatment?
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No
Yes
What is the Current Location?
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Counselor/ Treatment Phone #
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Expected Discharge Date?
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Primary Care Physician Phone #
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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
Counselor/ Treatment Phone #
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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