Application for Recovery Housing

Your Personal Information

Name *

First

Middle

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth

Month *

Day *

Year *

Home or cell phone *

Work phone *

Email *

Email

Confirm Email

Addiction Information

Are you an alcoholic?

Yes
No

Date of your last drink?

Are you addicted to drugs?

Yes
No

Date of last drug use?

List drugs you've used addictively

When did you attend your first AA or NA 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 'yes', who is your employer?

Are you getting welfare or other non-job related income?

Yes
No

If 'yes', what?

If you do not have a job, will you get one?

Yes
No

What is your monthly income right now?

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

Marital status (select one)

Do you have a medical doctor?

Yes
No

If 'yes', list the doctor's name and phone number

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 take prescription drugs?

Yes
No

If 'yes', list the drug and the reason the drug was prescribed

Move-In Information

Date of move-in?

Immediately
Other

If 'Other', list the date you would want to move in, if accepted

Have you ever lived in sober living before?

Yes
No

If 'yes', provide the name and location of the sober home and answer the next question

(Answer this question if the answer to the previous question was 'yes') - I left the previous sober home for the following reason

Relapse
Voluntarily
Other reason(s)

Other reason(s), if applicable

Do you owe money to the Oxford House you left?

Yes
No

If you do owe money to the Oxford House you left, do you agree to repay the money you owe to your former Oxford House?

Yes
No

Emergency Telephone Numbers

List family doctor, if you have one, plus two family members or friends

Name & Address

Relationship

Telephone

I understand that the Value Housing Nevada Inc. home to which I am applying will have its own set of policies and procedures that I must follow. Should I choose to act in opposition to the policies and procedures of the home, I forfeit my right to living in the home, and any refund of deposits and rent. These policies and procedures will be presented to me prior to my acceptance and agreement to living in the home.

Use this space for additional relevant information

I have read all of the material on this application, including the limitations set forth. I have also answered each question honestly and want to achieve comfortable recovery from alcoholism and/or drug addiction without relapse.

By checking the 'Yes' box below, I agree to the information & terms I have read in this form and agree to submit my information via this online form *

Yes

Helping Others Help Themselves

Online Application for Residency with Value Housing Nevada, Inc.

Your Personal Information

Addiction Information

Move-In Information

Emergency Telephone Numbers

VALUE HOUSING NEVADA, INC.