Safe Haven Sober Living — Resident Application

Step 1 of 7

Personal Information

Please fill out all fields accurately. This information will be kept confidential and used only for program purposes.

📋 Fields marked * are required.

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Basic Information

First Name *

Last Name *

Preferred Name / Nickname / AKA

Marital Status

Date of Birth *

ID / Driver's License # & State

Phone Number

Email Address

Present Address

Previous Address

Step 1 of 7

Step 2 of 7

Housing History & Emergency Contact

Tell us about your housing background and who we should contact in an emergency.

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Housing History

Have you lived in sober housing before? If yes, where:

Reason for leaving previous sober house

Preferred House

Final assignment is at the discretion of Safe Haven staff.

Anticipated Move-In Date

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Emergency Contact

Family Member Name(s)

Family Member Contact #

Emergency Contact Name & Relationship *

Emergency Contact Phone *

Relationship to Emergency Contact

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Step 3 of 7

Referral & Legal

Tell us how you found us and about any legal history.

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Referral Information

How did you hear about Safe Haven Sober Living?

Referring Organization (if applicable)

Contact Person / Number

⚖️

Legal Information

Are you presently in the legal system?

Have you ever been convicted of a crime?

List any current Parole / Probation Officers and contact numbers

List any Court Requirements

⚠️ By submitting this application, I acknowledge that I am not a registered sex offender and I have no prior arson-related charges or convictions.

Step 3 of 7

Step 4 of 7

Employment & Financial

Tell us about your employment and how program fees will be covered.

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Employment Information

Current Employment Status

Present Employer

Supervisor Name / Contact

Current Work Schedule

If unemployed, are you seeking employment?

If unemployed, receiving unemployment benefits?

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Financial Information

The program fee is $750.00 per month, payable prior to admission and on the first of each month thereafter.

How will your guest fees be paid?

Self-Pay DSS Family Assistance Other

Monthly Income Source

Responsible Party (if different)

Insurance Company / Policy #

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Step 5 of 7

Sobriety History

This information helps us understand your recovery journey and provide the best possible support.

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Substance History & Recovery

Drug of Choice

Age When Started Using

Date of Last Use

Sobriety / Clean Date

Most Recent Treatment Facility

Prior Recovery / Sober House Experience

Substance History

Do you attend or plan to attend 12-Step meetings?

Yes — AA Yes — NA Yes — Other No

Do you currently have a Sponsor?

Home Group (if any)

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Step 6 of 7

Medical Information

All health information is kept strictly confidential and used only to support your wellbeing during your stay.

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Health & Medications

Do you have any medical conditions?

List ALL medications currently being taken (name, dosage, frequency)

⚠️ All medications must be kept in a locked safe/box provided by the resident.

Are you on Medically Assisted Treatment (MAT)?

Have you been diagnosed with a mental health condition? If yes, explain:

History of suicide attempts or ideation?

Currently receiving therapy or counseling?

Step 6 of 7

Step 7 of 7

Certification & Signature

By signing below you confirm all information provided is accurate and complete.

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Certification

I certify that the information provided in this intake application is accurate and complete. I understand that providing false information may result in denial of admission or removal from the residence.

Print Full Legal Name *

Date

Signature — Type full legal name *

By signing, I certify that all information in this application is true and accurate to the best of my knowledge.

Step 7 of 7

Safe HavenSober Living

Application Submitted!

Safe Haven
Sober Living