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Applicant First Name *

Applicant Last Name *

Applicant Email ONLY ***IF YOU ARE A SW OR CASE MANAGER, DO NOT PUT YOUR EMAIL HERE. LEAVE BLANK IF YOU DO NOT HAVE THE APPLICANT'S EMAIL.

Applicant Phone ONLY ***IF YOU ARE A SW OR CASE MANAGER, DO NOT PUT YOUR PHONE # HERE. LEAVE BLANK IF YOU DO NOT HAVE THE APPLICANT'S PHONE #..

Marital Status *

Driver's License # or WA ID #: (if suspended or revoked, please put N/A) *

Sobriety Date *

Do you have a Case Manager? *

Yes

No

Case Manager Name

Case Manager Phone #:

Have you ever been in a treatment program? *

Yes

No

If yes, what was the most recent treatment start date: *

Length of Stay

Did you complete the program?

Yes

No

Have you ever lived in a recovery home? *

Yes

No

Are you currently attending 12 step meetings? *

Yes

No

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Phone #: *

Emergency Contact Address:

Are you capable of paying rent or monthly dues? *

Yes

No

Other

How will rent, dues, or any other fees be paid? *

Are you currently employed? *

Yes

No

Current Monthly Income $ *

Are you capable of working/volunteering? *

Yes

No

Criminal History (Check all that apply from your lifetime) *

Do you have a Parole Officer / Probation Agent? *

Yes

No

Number of lifetime DWI's / DUI's: *

Have you previously been convicted of a felony? *

Yes

No

Are you under a physician’s care? *

Yes

No

Have you ever planned suicide? *

Yes

No

Reference #1 Name *

Reference #1 Years Known *

Reference #1 Phone number: *

Reference #1 Relationship to you: *

Reference #2 Name

Reference #2 Years Known:

Reference #2 Phone number

Reference #2 Relationship to you

Upon acceptance, you will be expected to enter into an Agreement wherein you will agree to abide by certain rules and standards of conduct. Do you acknowledge this expectation? *

Yes

No

Applicant Signature *

Clear

Today's Date *

Application

Emergency Contact Information

Financial Information

Chemical Use History / Legal Involvement

Physical & Mental Health

References

Agreements

Submit

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