Online Application - Lorraine's House

First Name *

Last Name *

Address *

Phone Number *

Date of Birth *

Are you an Alcoholic? *

Yes
No

Date of your last drink?

Are you addicted to drugs? *

Yes
No

List of drugs you use addictively?

Date of last drug use?

When did you attend your first NA or AA meeting? *

How many AA/NA meetings do you now attend each week? *

Do you want to stop drinking alcohol and using addictive drugs?

Yes
No

Are you employed? *

Yes
No

If you do not have a job will you get one? If yes, what job plans do you have? *

Are you on welfare or other non-job related income? (See question below) *

Yes
No

If 'yes" what?

What is your monthly income right now? *

What do you expect your income to be next month? *

Marital Status (check one) *

Ethnicity *

Have you ever been to a treatment facility for alcoholism and/or drug addiction? *

Yes
No

If 'yes" list the treatment provider, phone number, and primary counselor, if any.

Do you have a medical doctor? *

Yes
No

If 'yes" list the doctor's name and phone number.

Do you take prescription drugs? *

Yes
No

If 'yes" list drugs and reason the drug has been prescribed.

Vaccination status? *

Yes
No

Negative Covid Test? *

Yes
No

Date of move in? Please list the date you would like to move in (if accepted). If the date is in the future, why? *

Have you ever lived in a Sober Living home before? If 'yes" provide details and answer the question below. *

If 'yes" to question above for what reason did you leave the previous sober living home?

Do you owe money to the Sober Living home you left?

Yes
No

Do you agree to repay the money you owe to your former sober living home?

Yes
No

List all legal charger and arrests below (Charge, date arrested, date convicted, Incarcerated ?, Status. If none, list none. *

Have you ever been charged or convicted of a violent crime? If 'yes' please explain.

I have read all of the material on this application form. I have answered each question honestly and want to achieve comfortable recovery from alcoholism and/or drug addiction without relapse. Please type your name below. *