Form 2

First Name *

Last Name *

Date of Birth *

Phone *

Street Address *

Apt, Suite, Bldg. *

City *

State *

Zip *

Sobriety Date *

Do you have a sponsor? *

If yes, please list name & phone number: *

Do you have a Home Group? *

If yes, please list day, time, and location: *

If at an inpatient treatment center, please list counselor’s/contact person’s name and phone number. *

Why do you want to live in recovery housing? *

What does recovery mean to you? *

Please use this space for any comments or questions. Additionally, if there anything else you'd like to share?

Are you currently employed? *

If yes, please list place of employment: *

Are you currently attending school? *

If yes, name of current school: *

At what age did you start using alcohol/drugs? *

What is your drug(s) of choice?

AlcoholMarijuanaPain PillsBenzodiazepines/TranquilizersPowder CocaineCrack CocaineHeroinMethadoneSuboxoneHallucinogensCrystal MethKetamineEcstasySolvents

Other: *

Have you ever been in any treatment programs? (detox, rehab, hospital for your use of drugs/alcohol) *

If yes, provide name, location, and dates: *

What is the longest amount of sober time you have had? When? *

Do you have any medical conditions? *

If yes, please specify. *

Do you have Health Insurance? *

Are you currently taking any medications? *

If yes, please provide a list and dosage amounts. Also include vitamins, nasal sprays and any over the counter medicine. *

Please note: It is VERY important that you list ALL medications taken in the last 7 days, regardless if you think it is important. Failure to list a drug that could show up on a drug screen will result in immediate termination from residence.

Are you Bulimic? *

If yes, when was the last time you binged and/or purged? *

Do you have a mental health diagnosis? *

If yes, please specify: *

Are you presently or have you ever self-harmed? *

If yes, when was the last time you self-harmed? *

Are you Anorexic? *

If yes, when was the last time you restricted? *

Do you have a counselor/therapist/psychiatrist? *

Counselor Name *

Counselor Phone *

Counselor Email Address *

Have you ever been convicted of a crime? *

If yes, please provide a list of all offenses, dates and disposition. *Please note: Signing this form gives authorization to perform a background check. Failure to disclose information found on a background check will result in immediate termination from residence.

Are you a registered sex offender? *

Are you currently on probation, court order, house arrest, or parole? *

If yes, please provide offense and details: *

Name of Probation Officer: *

Probation Officer Phone *

Name: *

Phone: *

Name: *

Phone: *

Instructions By signing below, you confirm that all information supplied is factual. You completely understand all of the questions you have answered. You understand failure to disclose any requested information will result in immediate terminate from residence, with no refund.

Signature: *

Today's Date: *

You have read and agree to follow ALL House Rules listed below. You understand failure to comply with any of the House Rules could result in immediate termination from residence, with no refund. (initial here): *

You have read and agree to pay all fees at the time payments are expected. Failure to comply within a reasonable time frame could result in immediate termination from residence, with no refund. (initial here): *

The Woodrow Project Application

Employment/Education:

Chemical Use

Medical

Legal

Emergency Contact

Verification

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