Application for Membership - Barbara K. Brooks

Print Name (Last, First, Middle)

Present Address (Street)

Check if treatment facility

Address

City

State/Province

Zip/Postal

Date of Birth

Phone Where You Can Be Reached

Home

Work

Are you an Alcoholic?

Yes

No

Date of Your Last Drink?

Are you addicted to drugs?

Yes

No

Date of last drugs use?

List drugs you used addictively:

When did you attend your first AA or NA meeting?

How many AA/NA meeting do you now attend each week?

Do you want to stop drinking alcohol and using addictive drugs?

Yes

No

Are you employed?

Yes

No

Who is your employer?

Are you getting welfare or other non-job realted income?

Yes

No

What?

If you do not have a job will you get one?

Yes

No

What job plans do you have?

What is your monthly net income right now?

$

What do you expect your monthly net income to be next month?

$

Marital status [Check one]

Married

Never Married

Separated

Divorced

Do you have a medical doctor?

Yes

No

List the doctor's name and phone number:

Doctor

Phone Number

Add Remove

Have you ever been to a treatment facility for alcoholism and /or drug addiction?

Yes

No

List the treatment provider, phone number and primary counselor, if any.

Do you take prescription drugs?

Yes

No

List the drugs and reason the drug has been prescribed.

Date of move in?

Immediately

other

List the date you would want to move in, if accepted, and why the date is in the future rather than immediately.

Date

Reason:

Have you ever lived in a recovery house before?

Yes

No

Provide the name and location

I left the previous Recovery House for the following reason: [check one]

relapse

voluntarily

other reason(s)other reason(s)

I, did or do not owe money to the House I left.

Yes

No

Emergency Telephone Numbers [List family doctor, if you have one, + two family members or friends]

Name and Address

Relationship

Telephone

Add Remove

I realize that the Transitional home to which I am applying for residency has been established in compliance with the conditions of § 2036 of the Federal Anti-Drug Abuse Act of 1988, P.L. 100-690, as amended, which provides that federal money loaned to stat the house requires the house residents to (A) prohibit all residents from using any alcohol or illegal drugs, (B) expel any resident who violates such prohibition, (C) equally share household expenses including the monthly lease payment, among all residents, and (D) utilize democratic decision making within the group including inclusion in and expulsion from the group. In accepting these terms, the applicant excludes himself or herself from the normal due process afforded by local landlord-tenant laws.

Use this space for additional relevant information:

I have read all of the material on this application form. I have also answered each question honestly and want to achieve confortable recovery from alcoholism and/or drug addiction without relapse.

Date