Oxford House Reentry Application

To be accepted in an Oxford House an applicant must complete all of this application. Based on this application the residents of the house vote on acceptance. An 80% affirmative vote is needed to be accepted. Carefully read the application and honestly answer the questions. Living in an Oxford House is special and if you understand its value it can help you achieve comfortable sobriety without relapse.

Email *
Are you filling this form out for another individual? *
If yes, are you willing to be contacted about this individual and their acceptance into a specific Oxford House?
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If yes, what is you name and phone number?  If no, is there a specific person that can be contacted, (name & number)?
Name (First & Last) *
Present Address *
Date of Birth *
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Phone Number you can be reached at or a family member, friend or case manager.   *
Are you an Alcoholic? *
Date of your last drink?
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Are you addicted to drugs? *
Date of last drug use?
MM
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Are you in recovery from substance use? *

Have you ever attended a support group or received treatment services for substance use or abuse?

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When was your 1st attempt at recovery?
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What groups or meetings are you attending to help you in recovery?

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Do you want to stop drinking alcohol and/or using addictive drugs?

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Are you employed? If “yes” who is your employer?

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Are you getting welfare or other non-job related income? If “yes” what?

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If you do not have a job will you get one?

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If “yes” what job plans do you have?

What is your monthly income right now?

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What do you expect your monthly income to be next month?

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Marital status [Check One]

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Do you have a medical doctor?

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Have you ever been to a treatment facility for alcoholism and/or drug addiction?

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If yes list the name of the facility

Do you take prescription drugs? If “yes” list drugs and reason the drug has been prescribed.

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Projected Date of Release: 

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(If this date changes you will need to notify the house)
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Have you ever lived in an Oxford House before? 
If “yes,” provide the name and location of the Oxford House below and answer the following question.

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I left the previous Oxford House for the following reason: relapse, voluntarily, other & Explain the circumstances

Do you owe any Oxford House any money? *

If you do owe money to the Oxford House you left,  Will you agree to repay the money owed to the former Oxford House.

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Emergency Telephone Names & Numbers. [List doctor, if you have one, + two family members or friends]

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I realize that the Oxford House to which I am applying for residency has been established in compliance with the conditions of § 2036 of the Federal Anti-Drug Abuse Act of 1988, P.L. 100-690, as amended, which provides that federal money loaned to start the house requires the house residents to (A) prohibit all residents from using any alcohol or illegal drugs, (B) expel any resident who violates such prohibition, (C) equally share household expenses including the monthly lease payment, among all residents, and (D) utilize democratic decision making within the group including inclusion in and expulsion from the group. In accepting these terms, the applicant excludes himself or herself from the normal due process afforded by local landlord-tenant laws.

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DOC #
DOC Facility/or county Jail? *
Gender *
DOC/Jail Counselor or Contact person at facility (name & phone number) *
Drug (s) of Choice  *

What is your current conviction and what circumstances led to your conviction? Please explain in detail

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Do you have any other legal issues Court dates.. Warrants, Detainers

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If yes please explain

Have you ever been arrested for any registerable sex crimes?

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If yes please explain.

What is your plan for recovery?

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Do you have a sponsor?

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If you currently do not have a sponsor will you get one?

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How many 12 step meetings do you attend per week?  What kind?

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How many 12 step meetings will you attend per week when released?

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What step are you on now?

Have you identified your relapse triggers

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If yes, what are they?

Tell us what your behavior might be like when you are headed towards a relapse?

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How do you plan on paying your share of living expenses? Expenses are due weekly. Falling behind puts you at risk of restrictions or expulsion.

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How do you feel about sharing a bedroom / group living?

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How do you handle confrontation?

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Can you confront others in a constructive manner? How?

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Have you ever attended anger management?

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If yes please explain

Are you involved in a relationship?

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Do you have children?

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If yes, will they be visiting you on weekends or holidays?

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Do you have any medical problems or mental disorders?

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If yes please explain

What do you feel you can contribute to Oxford House?

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What do you hope to achieve by living in an Oxford House?

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Do you have any prejudices? Race / Sex / Religion?

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If yes please explain

Do you have any problems performing house chores?

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What City & State would you like this application to go to?  If there are no locations in that specific area would you like it sent to the closest locations?  For a national directory of houses go to www.oxfordvacancies.com
Please feel free to use this space to add anything you feel like the Oxford House should know
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