Name
First Name
Last Name
Preferred Name (Nickname):
Former Name(s):
Sex
*
Marital Status (select one):
*
Present Address:
*
With whom do you presently live and what type of relationship(s) is involved (i.e. mother, child, friend, etc.)?:
Do you have a valid photo ID/driver's license?
Do you possess your birth certificate?
Do you have a valid food card?
Do you currently receive any government subsidies or assistance/benefits?
Present Employer:
Occupation:
Employer's Address - Street:
Employer's Address - City:
Employer's Address - State:
Employer's Address - Zip Code:
Supervisor's Name:
Supervisor's Phone:
May we contact your supervisor to verify emloyment?
Approximately what amount do you earn weekly?
Are you responsible for child support?
If yes, what amount do you pay weekly for child support?
Do you have other means of income?
If yes, please explain:
Alcohol
Time Clean / Sober:
Opiates
Time Clean / Sober:
Amphetamines
Time Clean / Sober:
Marijuana
Time Clean / Sober:
LSD
Time Clean / Sober:
PCP
Time Clean / Sober:
Cocaine, Crack
Time Clean / Sober:
Heroin
Time Clean / Sober:
Barbiturates
Time Clean / Sober:
Methamphetamines
Time Clean / Sober:
Hash, THC
Time Clean / Sober:
Inhalants
Time Clean / Sober:
Benzodiazepine
Time Clean / Sober:
Over the Counter Drugs
Time Clean / Sober:
Other
Time Clean / Sober:
If 'over the counter' or 'other' was selected, please list types in detail:
Have you received treatment (inpatient or outpatient) for drug / alcohol abuse?
Please give details: type of treatment, date of treatment and why you believe the treatment was successful or unsuccessful for you:
Have you lived in other sober living environments and/or halfway houses?
Please list dates and reason(s) for leaving:
What, if any, negative consequences have you incurred as a result of drug or alcohol abuse?
Depression
Sleeplessness
Abnormal Fears
Nightmares
Frequent Illness
Bipolar Disorder
Cutting
Low Self-Esteem
Inadequacy
Mood Swings
Anger
Seizures
Hearing Voices
Recurring Illness
High Anxiety
Self Punishment
Excessive Worry
Other
If desired, please give details of the above checked items here:
Have you ever been formally diagnosed, by a licensed psychiatrist, psychologist or general practitioner, for any mental or emotional disorder?
If Yes, please give details below (doctor, diagnosis, any medications prescribed):
Do you suffer or struggle with other compulsive behaviors besides addiction (for example, anorexia, bulimia, sex, hand-washing, thoughts, etc)?
If Yes, please explain:
What, if any, prescription or over-the-counter drugs do you take on a regular basis? Please list all medications and the purpose for taking them:
Are you presently seeing a mental health professional?
If Yes, please list location, doctor(s), frequency of visit(s) and phone numbers:
Please checkmark any of the following activities in which you have been involved:
Please provide details on the above selected items:
Other spiritual activities:
Describe the spiritual atmosphere (or lack of) in the family with which you grew up:
It is a requirement to have completed steps 1-3 to reside in the Sober Living Environment. Please place a check by the following steps, indicating that you have done so:
If you have a sponsor, please provide their name and phone number:
Do you regularly participate in AA, NA, or any other 12-step meetings?
If yes, indicate type and location:
Please indicate any health issues:
Primary Physician:
Dentist
Insurance Provider
Do you participate in regular exercise?
If so, please indicate type of exercise, how long you exercise and how often:
Do you feel you are over- or under-weight?
How healthy, in general, do you feel?
Please indicate the date and type of any felonies or misdemeanors in which you have been found guilty (other than minor traffic violations, DO include DUIs, Hit & Run, etc.):
Have you ever been incarcerated for any of the above convictions?
*
If so, please list location and dates of incarceration:
Are you required to register as a sexual offender?
*
Are you presently on Parole or Probation?
*
If so, please list officer in charge:
Have you ever received treatment in lieu of conviction?
*
If so, please explain:
Why do you desire to live in a Transitional Living Environment?
What are your five greatest strengths & your five most limiting weaknesses?:
Tell us about your goals and/or dreams for your life:
Reference #1
First Name
Last Name
Phone:
(###)
###
####
Reference #2
First Name
Last Name
Phone
(###)
###
####
Name
First Name
Last Name
*
First Name
Last Name
Phone:
*
(###)
###
####
Alternate Phone:
*
(###)
###
####
Maternity applicants MUST sign a release of information (pictured below) for Miami Valley Hospital's Promise to Hope Program. By typing your name below, you are signing this release of information electronically.
*
First Name
Last Name
