Redemption House Application

Referred by:

Last Name:

First Name:

M.I.

Phone:

Sobriety Date:

Drug of Choice:

Name of Insurance Company:

Member ID:

Age:

Date of Birth:

Height:

Weight:

Hair:

License or State ID:

Marital Status:

Children:

Car:

Y

N

Make:

Model:

License:

Emergency Contact:

Emergency Contact Tel. &num:

Relationship:

Employer:

Employer Tel.#:

Which detox/treatment program/jail are you coming from?

Active Restraining Orders:

Y

N

If yes, which court?

Probation:

Y

N

Probation Officer Name:

Parole:

Y

N

Parole Officer Name:

Open Criminal Cases?

Y

N

If yes, explain:

Medications Prescribed? Names/Dosage:

Have you ever resided in sober living Y/N?

Y

N

Name, location:

Approx Dates:

Reason for leaving:

List 3 positive things about yourself:

List 3 things about yourself needing improvement:

Why do you want to live at Redemption House?