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.

👤

Basic Information

First Name *

Last Name *

Preferred Name / Nickname / AKA

Marital Status *

Date of Birth *

Driver ID Number *

Insurance ID Number *

If you do not have insurance, put N/A.

Please send photo of Insurance and License to Safe Haven Staff.

Phone Number *

By providing your phone number, you consent to receive SMS messages about your account and payments. Message and data rates may apply. Reply STOP to unsubscribe.

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.

🏠

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 *

🆘

Emergency Contact

Family Member Name(s) *

Family Member Contact # *

Emergency Contact Name & Relationship *

Emergency Contact Phone *

Relationship to Emergency Contact *

Step 2 of 7

Step 3 of 7

Referral & Legal

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

📋

Referral Information

How did you hear about Safe Haven Sober Living?

Referring Organization *

Contact Person / Number *

⚖️

Legal Information

Are you presently in the legal system?

Have you ever been convicted of a crime?

Current Legal Involvement *

By initialing below, I confirm that I am not a registered sex offender and have no arson-related charges or convictions. *

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.

💼

Employment Information

Current Employment Status (select all that apply)

What school do you attend?

Present Employer *

Supervisor Name / Contact *

Current Work Schedule *

If unemployed, are you seeking employment?

If unemployed, receiving unemployment benefits?

Step 4 of 7

Step 5 of 7

Sobriety History

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

🌱

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 have a history of overdoses?

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 *

Step 5 of 7

Step 6 of 7

Medical Information

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

💊

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: *

Any psychiatric holds?

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.

✍️

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.

I acknowledge any information provided in this intake is true to the best of my ability and that false and omitted statements may result in termination.

Step 7 of 7

Safe HavenSober Living

Application Submitted!

Safe Haven
Sober Living