Recovery Alive Home Application

Print Name (Last, First, Middle)

Present address (Street) Check if treatment facility

Phone Where You Can Be Reached

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 used addictively:

When did you attend your first AA or NA meeting?

How many AA/NA meeting 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 you do not have a job will you get one?

yes No

If “yes,” what job plans do you have?

What is your monthly income right now?

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

Marital status [Check One]

Married Never Married Separated Divorced

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 drugs prescribed.

Date of move in ?

Immediately Other

If “other” list the date you would want to move in, if accepted, and why the date is in the future rather than immediately. Date: Reason:

Have you ever lived in a Recovery Home Before before?

Yes No

If “yes,” provide the name and location of the Recovery Home below and answer question below.

1. Answer this question if the answer to question above was “yes.”] I left the previous Recovery Home for the following reason: [check one]

Relapse Voluntarily Other Reasons

If 'other reasons' please list here:

2. I owe money to the Recovery Home I left.

Yes No

If I do owe money to the Recovery Home I left, I will agree to repay the money I owe to my former Recovery Home.

Yes No

Please and check if you agree:

I realize that the Recovery Alive Home (s) to which I am applying for residency (A) prohibits all residents from using any alcohol or illegal drugs, (B) expels any resident who violates such prohibition, (C) equally shares household expenses including the monthly lease payment, among all residents, and (D) utilizes democratic decision-making within the home. In accepting these terms, the applicant excludes himself or herself from the normal due process afforded by local landlord-tenant laws.

Use this space for additional relevant information:

Thank you for allowing us to share info about RA Home. Please print the attached application, scan the completed application back to us via email @ recoveryaliveoutreach@gmail.com. At that time, an in person or telephone interview will be scheduled.
RA Home
Member Expectations
● Members will attend church weekly and Christ Centered 12 Step Meetings at their local Recovery Alive Sponsoring Ministry.
● Once employment is established, residents are required to post their weekly work schedule and will be held accountable for employment attendance accordingly.
● Any member receiving social security will volunteer 20 hours a week.
Equal Share Expense
● Each resident will pay a one time non-refundable fee of $150.
● $160 per week includes electricity, water, heat, air, internet, and house phone.
● House supplies including cleaning supplies, toilet paper and paper towels will be provided through house shopping once a month.
Member Standards
● Each member will be drug tested coming in and must present a negative screen for admittance into RA Home.
● Each resident will be on a 30-day probation period.
● Residents are allowed to drive their own car if fully licensed, registered and insured. Only vehicles allowed at the home are fully insured and registered with the state.
● If a member is suspected of use, they will be screened for illegal substances and asked to leave the house if positive.
RA Home will work together to help the member find detox or a safe place to go, if desired. However, the member can’t stay on the premises longer than 3 hours and not at all if the return to use i ncludes any type of disruptive behavior.

Please read and check if you agree:

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

Please sign or type your name:

Please type date of form completion:

Recovery Alive Home Application

Recovery Alive Home Application

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