applicationForm

General Information

Name

Your Name is required to submit this form

Gender

Male Female Other (describe)

How do you self-identify your gender?

Phone Number

A phone number where you may be reached is required to submit this form

Email Address

Current Address

Date of birth

Social Security Number

Date of Last Use

Substance(s) of Choice

Are you currently in an inpatient facility?

Yes No

Inpatient Facility Location

Inpatient Facility Counselor's Name

Inpatient Facility Discharge Date

Have you received a recommendation to live in sober residence?

Yes No

Have you previously been at inpatient facility for substance abuse?

Yes No

Inpatient Facility Location

Inpatient Facility Discharge Date

Did you complete treatment?

Yes No

Have you ever lived in a sober living residence?

Yes No

Sober Residence Location

How Long Did You Live There?

Do you plan to continue outpatient treatment while in sober living?

Yes No

Describe your intended outpatient treatment

Are you currently involved with the legal system in any way?

Yes No

Explain your current legal involvement

Describe any previous arrests

Describe any previous convictions

Are you currently under parole or a suspended sentence?

Yes No

Medical History

When were you last seen by a physician and for what reason(s)?

Any hospitalizations in the past 2 years?

Yes No

Reason for the hospitalization(s)?

Are you currently being treated for a medical condition?

Yes No

Reason for treatment?

Are you currently prescribed any medications?

Yes No

Which medication(s), at what dosage(s), and at what frequency?

Have you ever attempted suicide?

Yes No

Are you currently contemplating suicide?

Yes No

Employment History

Please list the jobs you have held over the last 2 years

Are you currently employed?

Yes No

Where are you employed?

What is your job?

Financial Capacity

Are you able to afford rent?

Yes No

Do you anticipate future financial commitments that may cause problems paying rent?

Military History

Are you a veteran?

Yes No

In which military branch did you serve?

12-Step Program History

Describe any exposure to or participation in a 12 step recovery program:

Do you currently attend a local AA group?

Yes No

Which AA group(s)?

Do you currently have a sponsor?

Yes No

Sponsor name and phone number?

Emergency Contact #1

Name of emergency contact #1

Relationship to emergency contact #1

Home Phone Number of emergency contact #1

Cell Phone Number of emergency contact #1

Emergency Contact #2

Name of emergency contact #2

Relationship to emergency contact #2

Home Phone Number of emergency contact #2

Cell Phone Number of emergency contact #2

Conditions of Residency

The Road To Hope House Foundation will not admit as a resident, or allow to remain as a resident, any person who has been convicted of any of the following crimes of violence or an attempt to commit, or conspiracy to commit and in the same:

Murder, manslaughter, rape, criminal pedophilia, sexual exploitation of a minor, aggravated assault, riot, robbery, burglary, in the first or second degree, kidnapping, felony sexual contact or felony child abuse, all as the same are defined from time to time in state and federal law.

The Road To Hope Foundation will not admit as a resident or allow to remain as a resident, any person who is registered on any Sex Offender Registry or who is required to be registered on a sex offender registry.

I have answered all above questions truthfully:

Yes

I have answered all above questions to the best of my abilities:

Yes

Regarding the crimes of violence mentioned (above):

I have NOT been convicted, committed, or attempted

None of these stipulations will be violated by living here:

I certify this to be true

Sign & Submit

In accepting these terms, I, the applicant exclude my self from the normal due process afforded by local landlord tenant laws.

In addition I have read the application form and understand and agree that:

I fully subject myself to the rules of the house and will not be refunded if I am asked to leave. I have read and understand The Road To Hope House Foundation resident/member expectations and guidelines.

The nature of The Road To Hope Foundation requires expulsion without notice or refund of any resident who:

Is found to have used alcohol/drugs, has been violent or disruptive, has disregarded the house expectation, does not show financial responsibility and has not been timely in the payment of weekly/monthly rent, shows disregard for other conditions outlined in the Road To Hope House Foundation expectations and guidelines, and knowingly lied on this application.

Type your name and today's date to accept the terms below which exclude you from due process of local landlord tenant laws:

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Medical History

Employment History

Financial Capacity

Military History

12-Step Program History

Emergency Contact #1

Emergency Contact #2

Conditions of Residency

Sign & Submit