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Mission: (203)909-9194

Sober House: (475)238-4142

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The 180 House Online Application

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Personal Information

SS#:

First Name (required):

Last Name (required):

Previous Address (required):

City (required):

State (required):

Zip code (required):

Phone (123) 456-7890:

Your Email:

Place of Birth (required):

Date of Birth (Required):

Height:

Weight:

Eye Color:

Hair Color:

Marital Status:
SingleMarriedSeparatedDivorced


Emergency Contact

Name:

Phone (123) 456-7890:

Relationship:


Family Information

Father:

Phone (123) 456-7890:

Address:

Mother:

Phone (123) 456-7890:

Address:

Brother(s):

Sisters(s):

Husband/Wife/Significant Other:

Phone (123) 456-7890:

Children:

Address:


Personal History

Do you attend church? (where?):

What year were you saved or restored?:

Do you have any other religious affiliations? (Muslim, Catholic, Hindu, ETC.):

What are your reasons for joining The 180 House?:


Addiction History

Drug Used (1):

Frequency of Use (1):

Dosage (1):

First Used (1):

Drug Used (2):

Frequency of Use (2):

Dosage (2):

First Used (2):

Drug Used (3):

Frequency of Use (3):

Dosage (3):

First Used (3):

Drug Used (4):

Frequency of Use (4):

Dosage (4):

First Used (4):

Primary Drug Preferred:

Ever overdose?:
YesNo

Explain:

History of previous treatment?:

Do you smoke cigarettes?:

How many pack per day do you smoke?:


Medical History

Do you have any physical or medical problems?:
YesNo

Explain medical problems:

Any Allergies?:
YesNo

Explain Allergies:

Communicable Diseases?:

Have you ever had any same sex activity?:
YesNo

Have you had any psychiatric care?:
YesNo

Explain:

 

Are you under psychiatric care?:
YesNo

If yes, name of doctor or program:

 

Are you on Methadone or Suboxone?:
YesNo

If yes, name of doctor or clinical program:

List of all current medications (separate by commas):


Educational History

Highest grade completed:

GED?(leave blank if HS graduate):
YesNo

Training/Skills:


Employment History

Are you currently employed?:
YesNo

Average Monthly Income:
$

Current Employer

Employer Phone #:

Employer Address:

State:

Employer Zipcode:

When did you start working there?:

Previous Employer:

Previous employer's phone #:

How long did you work for this employer?:


Legal History

Do you have any pending court cases?:
YesNo

If yes, explain:

Lawyer's Name:

Lawyer's Phone, Ext.:

Are you currently on probation or parole?:

If yes, explain:

Officer's Name:

Officer's Phone:

Officer's Address:


Court, Charges, Disposition ***Does not influence eligibility*** this helps us help you.

Charges (1):

Date charges were filed?:

What state were charges filed? (two letter abbreviation):

Disposition:

Charges (2):

Date charges were filed?:

What state were charges filed? (two letter abbreviation):

Disposition:

Charges (3):

Date charges were filed?:

What state were charges filed? (two letter abbreviation):

Disposition:

Total time incarcerated?:


Financial Status

Do you have any financial issues that would make it difficult to pay rent?:

Do you receive any public assistance? (SSI, SSDI, EBT Food/cash):
YesNo

If Yes, Amount Food Stamps $: Amount Cash $:

Electronic Signature
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