Fill out the application . First Name *Last Name *Middle NameHave you ever been known by another name? *YesNoFirst NameLast NameBirthdateHow can we contact you to process this application?PhoneEmailPhoneEmailDo you consent to be contacted by The Promises Sober Living via SMS, email, or phone using the information I provided for the purposes of reviewing my application.YesNoDemographicsSexMaleFemaleDecline to sayEthnicityEthnicityDecline to answerAmerican Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhiteOtherAre you currently enrolled in school?YesNoWhat is the highest level of education you completed?High School /GEDCollege no degreeAssociate's degreeBachelor's degreeMaster's degreeProfessional degreeDoctorate degreeOtherAre you a veteran ? *YesNoDo you have any concerns with sharing a room ? *YesNoAre you able to perform household chores? *YesNoCurrent Living SituationWhat best describes your current living situation?I am living by myselfI live with my familyI am living with my roomate/roomatesI am living at a program, facility, or institutionI have no permanent place to live and I am currently homelessFamilyPersonal ContactsFirst NameLast NamePhoneFirst NameLast NamePhoneWhat is your marital status ?SingleMarriedEngagedDivorcedSeparatedDomestic PartneredAre you fleeing a domestic violence situation ?YesNoDo you have any children? *YesNoSubstance Use HistoryWhat is your drug of choice?AmphetaminesBarbituratesBensodiazepinesBuprenorphineCocaineEcstasy (MDMA)MethadoneMethamphetamineMorphineOxyPCPTHCAlcoholBath SaltsK2KratomHeroinOpiatesKetamineTCAFentanylWhat was the last drug used ?For how many years have you been using alcohol and/or drugs ?MedicalDo you have any allergies? *YesNoDo you have any physical health/medical conditions or disabilities ? *YesNoSelect all of the following that apply to you?Hepatitis AHepatitis BHepatitis CImmune System DisorderSexually Transmitted Diseases (STDs)Tuberculosis (TB)PregnantNoneDo you have a history of seizures? *YesNoDo you have any upcoming appointments or ongoing physical needs? *YesNoAre you currently under the care of any of the following provider types?NoneMedical DoctorPsychiatristPsychologistTherapistDo you have any medical equipment?NoneWalkerCaneGlucose MeterC-Pap MachineSpecialized PillowMental HealthDo you have any mental health issues or diagnosis?YesNoDo you have a history of self harm? *YesNoDo you have a history of self harm? *YesNoHave you ever experienced any suicidal ideations, attempts, or received in-patient treatment for self harming behaviors? *YesNoDo you have an Eating Disorder or Body Image Disorder? *YesNoDo you have a need for mental health services? *YesNoAddictive BehaviorsAre there patterns in other areas of your life that may have some addictive qualities?NoneInternetFoodRelationshipsMoneyShoppingDo you gamble?YesNoCommunicable DiseasesAre you at risk for exposure to any communicable diseases, or have you been in contact with someone who has? *YesNoAre you experiencing shortness of breath, coughing, fever, or other symptoms of Coronavirus and/ or a flu? *YesNoAre you at risk for exposure to Coronavirus? *YesNoHave you traveled outside of the country in the last 30 days? *YesNoMedicationsAre you currently using any prescription medications?YesNoAre you currently using any over -the-counter medication? *YesNoAre you participating in or about to enter any drug replacement program? *YesNoTreatment HistoryAre you currently in a treatment program? *YesNoHave you ever been to any treatment program?YesNoWhich one?RecoveryWhich 12 step meetings do you attend?NoneNarcotics Anonymous (NA)Alcoholics Anonymous (AA)SMART RecoveryCelebrate RecoveryOtherWhat is your Sober or Clean date? *Do you have a sponsor ?YesNoDo you have a Case Manager ?YesNoDo you have a Recovery Coach ?YesNoAssistance & HelpDo you have a disability or difficulty reading ?YesNoDo you have any immediate needs such as clothing or toiletries?YesNoDo you need assistance with locating support groups in the community? *YesNoDo you need assistance with legal work? *YesNoDo you need GED, vocational training resources? *YesNoDo you need assistance with locating food programs in the community? *YesNoCourts & LegalDo you have an attorney ? *YesNoDo you consent to a background check? *YesNoAre you currently involved in any legal proceeding or criminal justice issues? *YesNoDo you have a Community Service requirement? *YesNoDo you have a court ordered treatment requirement? *YesNoDo you have a pending sentence or any jail time upcoming? *YesNoHave you ever been charged or convicted of a Felony? *YesNoHave you ever been charged or convicted any violent crimes? *YesNoHave you ever been charged with cruelty to animals? *YesNoAre you affiliated with any gang? *YesNoRestrictionsSelect all legal requirements.NoneHouse ArrestProbationParoleDrug CourtOtherAre you required to register as a sex offender? *YesNoAre you required to register with any authority? *YesNoAre there any Restraining Orders against you or filed by you ? *YesNoAdmissionsWhen would you like to move in? *Have you lived in a sober home before? *YesNoHow long are you planning to stay with us? *30 days60 days90 days6mos1yrDid someone refer you to the The Promises Sober LivingYesNoWho referred you ?What are your goals and expectations from staying in sober living?Are you currently employed *YesNoWhat is your current occupation?Do you owe money to a former Sober Living Home? *YesNoAre you currently on disability? *YesNoTransportationDo you have a drivers license? *YesNoWhat is your primary mode of transportation? *Personal VehiclePublic TransportationFamily/FriendRegister
