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Referring Agency
Information about the agency that referred you
Agency
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Telephone number
Your answer
Case Manager
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Email address
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Mailing address
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Fax number
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Participant Information
Information about the person joining our sober house
First name
Your answer
Last name
Your answer
Address
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City
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State
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Zip code
Your answer
Phone number
Your answer
Social Security Number
Your answer
Email
Your answer
Date of birth
MM
/
DD
/
YYYY
Race
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Hispanic or Latino or Spanish Origin
Not Hispanic or Latino or Spanish Origin
Other
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Gender
Male
Female
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Documents
ID / Driver License
Birth Certificate
Social Security Card
Income Source
Employment - Monthly Income
Your answer
Social Security Disability - Monthly Income
Your answer
Housing
Have you previously rented a room from any sober houses in the past? If so please list below
Your answer
Have you applied to any low-income housing authorities? if so, which lists are you on?
Your answer
This is a shared room environment. Are you willing to share a room?
Yes
No
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Are you willing to leave the house between the hours of M-F 9:00am - 2:00pm?
Yes
No
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Legal
Do you have any pending legal matters?
Yes
No
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Are you willing to have your CORi/SORi run?
Yes
No
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Recovery status
Are you currently in recovery?
Yes
No
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Recovery / Sobriety Date
MM
/
DD
/
YYYY
Do you attend AA/NA meetings?
Yes
No
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Participant Signature
Your answer
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