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Please fill any applicable fields. |
| First
Name |
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| Last
Name |
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| Email |
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| Date
of Birth (mm/dd/yy) |
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| Current
Phone |
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| Current
Address or Facility |
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| Are you an Alcoholic? |
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| Date of Last Drink (mm/dd/yy) |
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| List drugs you take addictively: |
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| Are you addicted to drugs? |
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| Date of last drug use (mm/dd/yy) |
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| When did you attend your first AA/NA meeting? |
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| How many AA/NA meetings do you attend each week? |
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| List which meetings you attend each week |
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| Do you want to stop drinking alcohol and/or using drugs? |
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| Are
you employed? |
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so, who is your employer? |
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| Are you getting welfare or other non-job related income? |
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| If you do not have a job will you get one? |
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| If yes, what plans do you have? |
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| What is you monthly income right now? |
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| Marital Status |
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| Do you have a medical doctor? |
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| If yes, list name and phone number |
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Have you ever been to a treatment facility for alcoholism and/or drug addiction?
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| If yes list the treatment provider, phone number, and primary counselor. |
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| List any prescription drugs, and reason for the prescription. |
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| Do you have a sponsor? |
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| Sponsor's name |
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| Sponsor's phone number |
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| Date of move in? |
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| If other, List the date you would like to move in, if accepted and why the date is in the future rather than immediately. |
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Which steps have you completed? |
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Describe how you have completed the steps. |
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Emergency Contacts |
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| 1.
Name
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| Address |
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| Phone
Number |
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| 2.
Name
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| Address |
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| Phone
Number |
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| 3.
Name
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| Address |
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| Phone
Number |
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DOWNLOAD THE RETREAT RESIDENCE EXPECTATIONS |
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I
realize that this Sober House to which I am applying for residency
has been established in compliance with the conditions of 2036 Federal
Anti-Drug Act of 1988, P.L. 100-690 as amended which provides that
the house require the house residents to:
A)
Prohibit all residents from using any alcohol or illegal mind altering
substances.
B) Expel any resident who violates such prohibition.
C) Share household expenses including the monthly lease payments,
among all residents.
D) Utilize democratic decision making within the group including
inclusion and expulsion from the group.
In
accepting the terms, the applicant excludes himself or herself from
the normal due process afforded by local landlord tenant laws.I
have read all the material in this application form including the
limitations set forth above. I understand and agree that I fully
subject myself to the rules of the house and that deposits will
not be refunded if resident is required to leave. I have read and
understand the Retreat Residences Resident Expectations. The nature of
The Retreat Residences requires expulsion without notice or refund or security/sobriety
deposit of any resident member who is found by majority vote of
the house membership to be using either alcohol or drugs. Use, disruptive
behavior, disregard of the house expectations, or nonpayment of
fees can lead to immediate eviction. I have also answered each question
above honestly and want to achieve comfortable recovery from alcoholism
and or addiction. |
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| I
Accept
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I Decline |
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