Sober Living Application – Stepworks

Stepworks Sober Living Home Resident Application

Full Name (First, Middle, Last)*
Date of Birth*
Month
Day
Year
Social Security Number*
Current Address*
Home of Record*
ID/Driver's License (#/State)*
Verified Initials (House Manager/Administrator)
Emergency Contact*
Relationship to Emergency Contact*
Emergency Contact Phone Number*
Present Employer*
Current Supervisor*
Employer Phone Number*
Employer Address*
Have you ever been convicted of a crime?*
If yes, please explain
Are you currently in the legal system?*
If yes, please explain
List any current Probation/Parole Officers and their contact numbers
What are your drugs of choice (please explain)*
Have you ever been to a treatment facility?*
If yes, please explain
Please list any medications you are currently taking and why
Sobriety Date (If applicable)
Month
Day
Year
Do you have a sponsor?*
Sponsor's name and contact numbers
Have you ever been in a recovery house, halfway house, or similar facility?*
If yes, please explain
Applicant Signature*
Date*
Month
Day
Year
Staff Signature
Date
Month
Day
Year