Your Name (First & Last)

Drivers License or State ID

Are you a veteran?
YesNo

Marital Status
MarriedDivorcedSeparatedWidowedPartnership

What Is Your Physical Mailing Address

Your SSN (only enter the last 4-digits)

Desired date to move in to Guiding Light House

What are some of your best characteristics?

Do You Have A Primary Physician?
YesNo

Your Email Address

Do you have a car?
Yes, Currently InsuredYes, Currently Not InsuredI Do Not Own A Car

Are you pregnant?
YesNo

Highest Level of Education
High-SchoolCollegeGraduate SchoolVocational or Technical Institute

Current Mailing Address (if different than your physical address)

Your Date of Birth

Your Phone Number

Hobbies and Interests

If you have a primary physician, what is their contact information?

Have you been arrested in the past 30 days?
YesNo

Are you currently on probation?
YesNo

If you're on probation who is your probation officer? Contact number?

Have you ever lived in a home shared by other people? (if yes explain)

What is your monthly gross income?

Do you own or rent?
RentOwnLive With Family

Do you anticipate any problems with sharing space with others?

Do you receive additional income explain or welfare?

How much do you pay monthly? (if applicable)

Current Treatment Center (if applicable)

Who Referred You?

What is your primary addiction and your last date of use?

Do you think you have a problem with alcohol?

Do you think you have a problem with drugs?

FIRST DRUG:

SECOND DRUG:

THIRD DRUG:

FOURTH DRUG:

FIFTH DRUG:

SIXTH DRUG:

Route In Which You Were Exposed?

Route In Which You Were Exposed?

Route In Which You Were Exposed?

Route In Which You Were Exposed?

Route In Which You Were Exposed?

Route In Which You Were Exposed?

Name of person not residing with you?

Telephone Number

Relationship

Address

Name of person not residing with you?

Telephone Number

Relationship

Address

Name of person not residing with you?

Telephone Number

Relationship

Address

Current Employer

Position

Which days do you work?

Address

Phone

How many previous recovery attempts/relapses have you had?

How long have you been clean or sober?

Do you take any prescriptions?
YesNo

List any prescriptions you're taking

When did you attend your last AA or NA meeting?

Do you already have a sponsor or a Recovery Coach? (if yes, share their name and contact)

What's the longest you've gone substance free?

Do you have any medical conditions or allergies:
YesNo

List any medical conditions or allergies

How many meetings have you attended in the last 30 days:

Do you have any other recognized addictions or disorders (i.e. Eating disorder, cutting):

Are you on any maintenance programs, and if so, which:

Applicant Name

Date