Date of Application *

First and Last Name *

Have you ever applied to VFOR before? *

Have you ever lived in a VFOR Home? *

Gender of Applicant *

Date of Birth *

Applicant's Phone Number *

Applicant's Email Address (if you do not have one, please register one immediately. All VFOR members are expected to have one). *

Please provide emergency contact name, number and relationship. *

Rehab or Institution name (if other, please specify) *

Estimated Program completion date or program completion date *

Case manager's contact information (Name, number, email). *

Have you been to treatment before? If so, where and when? Did you complete your stays? If you left against medical advice, please state the reason for leaving. *

Have you been to outpatient treatment before? If so, where and when? Did you complete the program? If you left against medical advice, please state the reason for leaving. *

Please list all prescribed medications you are currently taking *

Do you have any allergies? If so, please name them. *

Are you on state or private insurance? (State = Medicaid or Medicare) *

Do you have a primary care physician outside of your rehabilitation institution? If so, where are they located? *

Where do you currently reside? (If homeless or in a housing crisis, please list the town you were last staying in). *

Do you have a driver's license? *

If not, what do you have to do to get it back? *

Do you own a registered motor vehicle? *

Are you currently pending any charges? If yes, please provide a complete list with your court dates. *

Have you ever been convicted of any charges, state or federal? Civil or criminal? *

Are you on any type of supervision? If so, what kind? *

If you are on any type of supervision, who is your supervising officer (name, email, phone number). If not on supervision, please put "None" *

Will you sign a release for VFOR to talk to your supervising officer? *

Please list your employment history in the past five years. *

Do you have employment lined up? *

Do you have family that will support you financially, even temporarily? *

Move in dues are $450 for a VFOR home in Chittenden county and are $445 for the rest of the homes. Do you have the money required to move in? *

Do you have any diagnosed chronic health problems or mental health disorders? If so, please list them. *

What location are you interested in? If you are willing to go anywhere, your chances of getting a bed increase dramatically (please select Multiple). *

Sobriety/Clean date? *

What is your preferred recovery path? (Example, 12-Step, non-12-step, SMART recovery, etc) *

What led you to seek recovery from substance use? *

Why are you interested in living in a recovery home? *

Do you have children? If so, do you have custody? Do you have any visitation requirements? *

What is your currently relationship with your family? Do they support you in your journey into recovery? *

Have you done any self-help groups before? (12-Step, SMART recovery etc)? *

Do you have a sponsor, mentor or recovery coach? If so, how often do you meet with them? *

Do you have a therapist, psychiatrist, psychologist or counselor? *

If applicable, what are some contributing factors to relapses or slips? *

What does your recovery plan look like, aside from participating in the recovery community? *

What are your current and past substances of choice, or substances you've had the most problem with? *

Have you ever been an IV user? *

Have you applied to other recovery homes? If so, would you tell us which ones? *

Have you ever lived in a recovery home before? If so what terms did you leave on? *

Do you owe any recovery homes money? If so, how much and are you willing to be on a payment plan to pay them back? *

What strengths can you bring to our home? What benefit would that bring? *

If you were aware of someone using in the house, whether that be a house member or guest, how do you think you would handle that situation? *

If you had a slip or a relapse, how do you think you would handle that sitaution? *

If we didn't have a bed for you on your completion date, what would your living situation be? If you aren't in rehab, are you currently safe? *

If we had to ask you to leave, would you have a safe place to go? If so, where is that place? *

Would you be able to honor our 3-month commitment policy if you moved in? *

Do you have any questions that you would like a VFOR representative to answer for you during your interview? *