SVdP's Rosalie HouseRESIDENT APPLICATIONApplicant InformationFull NameDate MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneEmail EthnicitySocial Security NumberCounty of last residenceDo you have a valid CA ID or Driver’s license? Yes No If so, please provide your CA ID or DL#Expiration MM slash DD slash YYYY Emergency Contact InformationFull NameRelationPhoneEmail Background informationHave you ever been incarcerated? Yes No What facility?Release Date MM slash DD slash YYYY Reason for most recent incarcerationChargesLength of time served: (past and present)Date of first incarceration MM slash DD slash YYYY Past offensesDo you have any outstanding warrants or current court cases pending? Yes No If so, where?AttorneyPhoneEmail Have you scheduled a court hearing for this active case? Yes No If yes, please provide court hearing date and informationAre you currently, or will you be, on probation or parole? Yes No If yes, please provide your court ordered stipulations related to your probation and length of timeProbation Officer/ Parole Agent Name:PhoneAre you on an ankle monitor? Yes No Are you concerned about your safety? If so, please explainRelationship and Family InformationAre you currently in a romantic relationship? Yes No If yes, please explainAre you currently married? Yes No Spouse NamePhoneIf you have children, please list them below. If you need more space, please list at the end of the application:Please mention their full name, age and sex (M/F)Do you have any court orders related to your children? Yes No If yes, please explainEmployment InformationPlease list your employment history beginning with current employerCompanyPhoneAddressSupervisorJob titleFromToMay we contact your current employer? Yes No Supervisor PhoneCompanyPhoneAddressSupervisorJob TitleFromToCompanyPhoneAddressSupervisorJob titleFromToYou will be required to provide (2) of your most recent pay stubs or provide proof of income for the party responsible for paying your monthly expenses (family, friend, organization) Gross Monthly IncomeRecovery InformationTell us about your goals and plans (employment, education, family, personal, and spiritual growth). What do you hope to accomplish in your life?Have you completed an in-patient or out-patient recovery program within the last 60 days? Yes No FacilityFromToConsent By checking this box, I agree to provide my Certificate of Completion. The original document must be provided to staff during your first scheduled meeting. A copy is attached to this application. I understand my application will not be processed if a copy is not provided.Have you attended an additional program(s) in the past? (residential or non-residential) Yes No FacilityFromToCompleted?FacilityFromToCompleted?FacilityFromToCompleted?Why do you feel you are ready to be in a Sober Living Environment?What have been your biggest personal challenges in recovery?What do you think will be your biggest personal challenge moving forward?How will living in a Sober Living Home help with your reentry to society?Drug(s) of ChoiceBriefly explain your history and use with drugs and/or alcoholWhat other drugs, if any, have you used in the past? Please listHow long have you been clean and sober?Do you currently attend AA/NA meetings? Yes No CountyHome GroupDo you have a regular service commitment? Yes No Meeting NameService RoleDo you have a Sponsor? Yes No NamePhoneWhat step are you on?Have you dropped/reviewed this step with your current Sponsor? Yes No Medical InformationDo you have a medical condition or physical health issues? Yes No If so, please explain in detail and tell us how you maintain your healthHave you been diagnosed with a mental health disorder? Yes No What is your diagnosis and what age were you first diagnosed?Where did you receive this diagnosis?Clinician/FacilityContact InformationHave you ever been hospitalized for psychiatric reasons? Yes No Briefly explain circumstances and when this occurredPlease list the medications you are currently takingMention the medication, it's purpose and dosage.Are you currently prescribed any medication(s) for Substance Use Disorder? Yes No If so, please list medication name, strength and dosage:MedicationStrengthDosageDo you currently have Medi-Cal? Yes No If so, what county?Medical Record NumberHospital/ PhysicianDo you have other health insurance? Yes No Medical Record NumberProviderHave you recently had a physical exam or TB test? Yes No Date of last physicalHospital/ PhysicianConsent I affirm that the information given by me on this application is true and accurate. Upon submission, I agree to provide documentation confirming I have completed a recovery program within the last 60 daysConsent In addition, I have also provided my most recent paystubs or proof of income from the party responsible for my monthly expenses at SVdP’s RH.Consent I also understand that if I do not complete this application in its entirety and/or do not provide the required documentation, my application will not be considered, and I understand that I will need to complete a new application when I am able to complete all necessary steps. I understand that completing the application does not guarantee admission to the home. You may be required to apply at a later dateConsent I understand that more information may be required of me during the application processSignatureDate MM slash DD slash YYYY If you received assistance with filling out this application, please provide the contact information for that person below. If a family member, friend or agent, will be assisting you with your monthly expenses– please have them sign below and attach proof of income for that individual. Assistance provided by:NameRelation to applicantSignatureDate MM slash DD slash YYYY Δ
