Downlod Form Zach’s House on Ellery SOBER HOME/TRANSITIONAL LIVING APPLICATION Date Name DOB Age Current Address Phone Number Cell Phone Number Referred By Emergency Contact Name Relation City, State Phone Number Do you have a primary care physician? Yes No If Yes, Name Currently in Treatment? Yes No If Yes, Name of Treatment Center Case Manager/Counselor Contact Number Length of Stay at Treatment Facility Tentative Discharge Date If not currently in treatment, have you been in treatment in the past year Yes No Treatment Program Length of Stay Have you lived in a Sober Living Home before? Yes No Name City/State When Length of Stay Drug(s) of Choice Sobriety Date Which 12-step recovery program are you working? What meetings do you attend and how often? Do you have a Sponsor? Yes No If Yes, Sponsor’s first name and last initial If no, why not? What is your current source of income? Employer Address Supervisor Phone Number Job How long have you worked there? Do you have a driver’s license/state ID? Yes No Do you have a car or form of transportation? Yes No Current Medications, Dosage & Frequency: Are you participating in or about to enter a MOUD or other SUD program? Yes No Program name Contact information Applicant’s Name Applicant’s Signature Date House Manager or Director Signature Date Non-Discrimination: The landlord affirms that it does not discriminate against Tenant or applicants based on gender, sex, race, color, ancestry, religion, sexual orientation, military/veteran status, age, national origin, gender identity/gender expression, marital status or disability, in accordance with federal, state and local fair housing laws. Submit
