Application for Residence – New Beginnings Sober Living Home Ambler Pa
A Sober living community for men
We are currently accepting applications from men aged 18+. Anyone applying to live in the house must read the Resident Handbook and submit this completed application prior to interviewing, and must be clean & sober 30 days or successfully complete a residential treatment program. A minimum payment of $270.00 is required to move in ($100 entry fee + $170 first week).
PERSONAL INFORMATION
Print Your Full Name:
Phone#:
Social Security #:
Current Address:
Date of Birth:
Age:
Email:
Marital Status:
Own a vehicle?
Yes No
Valid Driver License?
Yes No
Year/Make/Model:
State Driver License #:
Current Living Situation City:
Drug(s) of Choice:
Name of Counselor:
RECOVERY INFORMATION
Are you an alcoholic?
Drug addict?
Date of Last Use:
Currently/recently in treatment? Yes No
Did you complete successfully? Yes No
Name & Location of Facility:
Discharge Date:
How do you plan to stay clean and sober?
Who referred you to New Beginnings Sober House?
(Name, Relationship & Phone)
Do you attend 12-step meetings?
If so, how often? Yes No
Have you lived in a recovery house before?
Name & Location of House?
Why did you leave there?
EMPLOYMENT INFORMATION
Are you employed? Yes or No
If Yes, Name & Location of Employer
Current Monthly Income?
What other types of work have you done?
Job Title Special Skills/Training?
How long employed?
If No, How long since last employed? Are you willing/able to get a job within 30 days?
Are you willing/able to be self-supporting?
Yes No
Will someone else be helping you pay rent or deposit? Yes No
LEGAL INFORMATION
Ever been incarcerated? When/How Long? Yes No
List Pending Charges/Cases/Warrants
Currently on probation/parole? Yes No
Name of Officer
List Felony Convictions
Location of Office
Contact Phone
Are you a registered sex offender?
Yes No
MEDICAL INFORMATION
Describe Any Injuries/Disabilities
Describe Physical Limitations Resulting from Disabilities
Name of Physician
List All Medical/ Psychiatric Conditions
List All Current Medications
Are you receiving Suboxone, Subutex, Methadone, Vivitrol, etc? Physician Prescribing Yes No
EMERGENCY CONTACTS (LIST TWO)
Name Relationship
Street Address City
Phone
State Zip
Name Relationship
Street Address City
Phone
State Zip
Questions? Contact Frank at (215) 932-0218 or newbeginningsol@outlook.com.
A Sober living community for men
We are currently accepting applications from men aged 18+. Anyone applying to live in the house must read the Resident Handbook and submit this completed application prior to interviewing, and must be clean & sober 30 days or successfully complete a residential treatment program. A minimum payment of $270.00 is required to move in ($100 entry fee + $170 first week).
PERSONAL INFORMATION
Print Your Full Name:
Phone#:
Social Security #:
Current Address:
Date of Birth:
Age:
Email:
Marital Status:
Own a vehicle?
Yes No
Valid Driver License?
Yes No
Year/Make/Model:
State Driver License #:
Current Living Situation City:
Drug(s) of Choice:
Name of Counselor:
RECOVERY INFORMATION
Are you an alcoholic?
Drug addict?
Date of Last Use:
Currently/recently in treatment? Yes No
Did you complete successfully? Yes No
Name & Location of Facility:
Discharge Date:
How do you plan to stay clean and sober?
Who referred you to New Beginnings Sober House?
(Name, Relationship & Phone)
Do you attend 12-step meetings?
If so, how often? Yes No
Have you lived in a recovery house before?
Name & Location of House?
Why did you leave there?
EMPLOYMENT INFORMATION
Are you employed? Yes or No
If Yes, Name & Location of Employer
Current Monthly Income?
What other types of work have you done?
Job Title Special Skills/Training?
How long employed?
If No, How long since last employed? Are you willing/able to get a job within 30 days?
Are you willing/able to be self-supporting?
Yes No
Will someone else be helping you pay rent or deposit? Yes No
LEGAL INFORMATION
Ever been incarcerated? When/How Long? Yes No
List Pending Charges/Cases/Warrants
Currently on probation/parole? Yes No
Name of Officer
List Felony Convictions
Location of Office
Contact Phone
Are you a registered sex offender?
Yes No
MEDICAL INFORMATION
Describe Any Injuries/Disabilities
Describe Physical Limitations Resulting from Disabilities
Name of Physician
List All Medical/ Psychiatric Conditions
List All Current Medications
Are you receiving Suboxone, Subutex, Methadone, Vivitrol, etc? Physician Prescribing Yes No
EMERGENCY CONTACTS (LIST TWO)
Name Relationship
Street Address City
Phone
State Zip
Name Relationship
Street Address City
Phone
State Zip
Questions? Contact Frank at (215) 932-0218 or newbeginningsol@outlook.com.