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SECTION 1: APPLICANT INFORMATION

Full Legal Name *

Date of Birth *

Gender

Phone Number *

Email Address *

Current Address

Emergency Contact Name

Relationship to Applicant

Emergency Contact Phone

SECTION 2: RECOVERY INFORMATION

Are you currently in recovery?

Yes No

Date of Last Use

Substance(s) of Choice

Are you currently participating in outpatient treatment?

Yes No

If yes, please explain

What are your current recovery goals?

Why are you seeking sober living at this time?

SECTION 3: HOUSING AND SUPPORT INFORMATION

Have you previously lived in a sober living residence?

Yes No

If yes, please explain

Were you referred by a program, agency, or individual?

Yes No

Referral Source

Case Manager/Counselor Name

Phone Number

Are you currently on probation or parole?

Yes No

If yes, please provide officer name and contact information

SECTION 4: EMPLOYMENT AND FINANCIAL INFORMATION

Current Employment Status

Employer Name (if employed)

Monthly Income (approximate)

Income Source(s)

How do you plan to pay residency fee? (Select all that apply)

Employment Family Support Assistance Scholarship/Grant Other

If other, please explain

SECTION 5: MEDICATION AND MEDICAL INFORMATION

Are you currently prescribed any medications?

Yes No

If yes, list medications and dosage

Do you have MAT (Medication-Assisted Treatment) prescription?

Yes No

Doctor Name

Doctor Phone Number

SECTION 6: TRANSPORTATION INFORMATION

Do you own or have access to a vehicle?

Yes No

If yes, vehicle make/model

SECTION 7: LEGAL AND SUPERVISION INFORMATION

Are you currently under any legal supervision?

Yes No

If yes, describe supervision type and requirements

Outstanding legal issues or pending charges?

Yes No

If yes, please explain pending charges

Are you required to register as a sex offender?

Yes No

If yes, provide registration details (tier level, registering jurisdiction, dates due)

SECTION 8: APPLICANT ACKNOWLEDGEMENTS

Please initial each item to confirm your understanding:

APPLICANT SIGNATURE

Applicant Signature (Type your full name) *

Date *

Phone: 888-894-2654 | Email: [email protected]

www.sunrisesoberliving.net

Application will be sent to [email protected]

Complete Online Application

SUNRISE SOBER LIVING RESIDENCE

SECTION 1: APPLICANT INFORMATION

SECTION 2: RECOVERY INFORMATION

SECTION 3: HOUSING AND SUPPORT INFORMATION

SECTION 4: EMPLOYMENT AND FINANCIAL INFORMATION

SECTION 5: MEDICATION AND MEDICAL INFORMATION

SECTION 6: TRANSPORTATION INFORMATION

SECTION 7: LEGAL AND SUPERVISION INFORMATION

SECTION 8: APPLICANT ACKNOWLEDGEMENTS

APPLICANT SIGNATURE

Download the Application Form

Questions About the Application?