Phone Where You Can Be Reached
Are you addicted to drugs?
Do you want to stop drinking alcohol and using addictive drugs?
Are you getting welfare or other non-job realted income?
If you do not have a job will you get one?
Marital status [Check one]
Do you have a medical doctor?
List the doctor's name and phone number:
Have you ever been to a treatment facility for alcoholism and /or drug addiction?
Do you take prescription drugs?
List the date you would want to move in, if accepted, and why the date is in the future rather than immediately.
Have you ever lived in a recovery house before?
I left the previous Recovery House for the following reason: [check one]
I, did or do not owe money to the House I left.
Emergency Telephone Numbers [List family doctor, if you have one, + two family members or friends]
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.
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.