Print Name (Last, First, Middle) (Full name, no initials)

Date of Birth 

Month

Day 

Year

Address (Street) Home address ONLY

Phone Where You Can Be Reached

Home ( ) 

City 

State 

Zip

Work ( ) 

 
Will you have your own transportation? Yes No

Social Security Number 

Are you getting SSI, Disability or other non-job related income? 

 Yes No If ‘yes’ what? 

Are you employed? Yes No 

If ‘yes’ who is your employer? 

Are you a recovering: 

 Alcoholic? 

 

 Drug addict? 

Your sobriety date: 

List drugs you used addictively: 

 
If you have been in substance abuse treatment, either in-patient or out-patient within the last five years, 
give the name of each program (i.e. detox, treatment center, halfway house), the dates you attended and 
the reason for leaving. 

 

 

 

 

 
Do you take prescription drugs? Yes No If ‘yes’ list drugs and 
reason drug has been prescribed. 

Name and phone of medical doctor 

Have you ever been convicted of a felony? Yes No If ‘yes’, 
explain: 

Marital status (Check One) 

 Married Never Married 

 

 Separated Divorced 

Are you participating in or about to enter a methadone or other drug 
replacement program? Yes No 

Drivers License Number 

State _______________ 

#____________________________ 

 

 

Have you ever lived in a sober house before? (i.e. Oxford House) Yes No If ‘yes’ provide name and 
location. 

 

If you have lived in a sober house before what was your reason for leaving? 

 

 



 


Name, address and phone number of your last landlord:

Date of move in? Immediately Other If ‘other’ list the date you would want to move in, if accepted, 
and why the date is in the future rather than now. Date: ____________ 

Emergency Telephone Numbers: 

1. 

 

 

2. 

 

• Current Treatment Center you are in (If Applicable)_______________________ 


• Your Case Manager or Counselor Name __________________________________ 


• Your CM or Counselor Phone & Fax #: ___________________________________ 


• Discharge Date:________________________________________________________ 




 

 

Dated:_____________ Signature:___________________________________________ 

 




 
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