Application Form

Sober 4 Life Inc
CJO House

(508)699-2500 www.sober4life.org

INTAKE APPLICATION

Application Information

Marital Status:

Married
Never Married
Separated
Divorced

Veteran:

Yes  
No  

Are you pregnant:

Yes  
No  
NA

Recovery and Substance Use:

Do you think you have a problem with alcohol?:

Do you think you have a problem with drugs?:

Do you have a sponsor?

Yes  
No  

If yes:

Do you have any other addictions or disorders: i.e. eating disorder, cutting, sex addict?

Yes  
No  

Legal:

Have you been arrested in the past 30 days:

Yes  
No  

Are you currently on probation or parole:

Yes  
No  

If yes:

Are you mandated here:

Yes  
No  

Please list any pending legal problems, i.e. Court dates, defaults, violations, warrants etc.

Do you have any active restraining orders against you or someone else?

Yes  
No  

If yes:

Medical:

Do you take any prescription medications:

Yes  
No  

If yes:

Do you have any medical conditions or allergies?

Yes  
No  

If yes:

Do you have a primary care physician:

Yes  
No  

If yes:

Employment:

Current work Schedule - Indicate Hours

List Last 2 Employers:

Are you receiving welfare, disability, assistance or other non-job related income?

Yes  
No  

If yes:

Do you have a valid driver’s license?

Yes  
No  

Do you have a car:

Yes  
No  

If yes, is it registered and insured?

Yes  
No  

Emergency Contact:

1

2

3

Emergency Contact:

Have you ever lived in a home shared with other people?

Yes  
No  

Do anticipate any problems with sharing the responsibilities of a community home?

Yes  
No  

References

I authorize the verification of the information provided on this form as to my legal and employment.

Signature of applicant: