Monolithic Recovery Housing Application
Please fill out this application completely and honestly. All information will be kept confidential.
Sign in to Google to save your progress. Learn more
Monolithic Recovery
Legal Name *
Date of Birth *
MM
/
DD
/
YYYY
Do you have a working phone and phone number, that isn't TextNow?
Clear selection
Current Phone Number *
Social Security Number
Email Address *
By what date do you need to move-in? *
MM
/
DD
/
YYYY
Current Address *
Emergency Contact Name *
Emergency Contact Phone Number
Emergency Contact Relationship *
Referred by? *
Can you pass a drug/alcohol screen? *
Date of last use of any substance (including alcohol) *
MM
/
DD
/
YYYY
Age of first use? *
What is the primary substance you have struggled with? *
Do you have a history of trauma? *
If so, please give a generalized description
Do you have a mental illness diagnosis? If yes, please list and what medications you are currently prescribed. *
Are you currently employed or actively seeking employment? *
If employed, where and what shift?
Are you able to pay $150.00 a week for program fees? If not, do you agree to pay your fees upon gaining employment? *
Do you currently receive EBT Benefits? (Food Stamps) *
Do you have a valid driver's license? *
Do you own a vehicle? *
Do you have a state issued ID? *
Do you have a Social Security card? *
Do you have a copy of your diploma or GED *
Are you on probation/parole? *
If yes to probation or parole, please give officers name phone number? *
Are you currently under supervision from Drug Court, Mental Health Court, or Veterans Court? If so which, what county, officers name, and phone number. *
Do you have any pending charges? *
If yes to pending charges, what are they?
Are you a sex offender? *
Do you currently have an EPO/DVO? *
If yes, who is the other party?
Have you ever committed arson? *
Have you completed a formal treatment program (e.g., detox, residential, IOP)? *
If yes, please list the name of the facility and dates of attendance. *
Have you been involved in or completed a Spiritual Pathways program held by Southeast Christian? *
If you are completing another treatment program, do they provide transportation to our facility? *
Have you ever lived in a sober living/halfway house before? *
Do you currently attend 12-Step meetings (e.g., AA, NA) or other recovery support groups? *
Are you currently sponsored? *
If your sponsor allows it, please provide his/her name and contact information (phone number or email)
Are you currently being prescribed narcotic medications? A yes response is not an automatic disqualification *
If yes to narcotic medications, what are you prescribed?
Are you disabled or require additional services? If yes, please explain
How important is maintaining a sober lifestyle to you right now? *
Not Important at All
Extremely Important
Please rate your agreement with the following statements regarding your commitment to recovery:
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I am fully committed to attending all required meetings.
I am willing to participate in household responsibilities/chores.
I accept the necessity of regular drug/alcohol screenings.
I am ready to accept feedback from staff and peers.
Clear selection
Which house rules do you feel might be the most challenging to follow? *
Required
What level of educational attainment have you achieved?
How did you hear about our Sober Living program?
Please provide a brief statement on why you are seeking residency in a sober living environment at this time. *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Monolithic Recovery.

Does this form look suspicious? Report

Google Forms