Apply - HOH Sober Living

House of Hope Foundation Recovery Residence Application

Name *

First

Last *

Last

Date of Birth *

Email *

Phone *

Additional Contact Phone

About You

Relationship Status: *

Nearest Relative *

Nearest Relative

Name

Address

City

State/Province

Zip/Postal

Home Phone

Work Phone

Mobile Phone *

Emergency Contact #1

Name

Address

City

State/Province

Zip/Postal

Home Phone

Work Phone

Mobile Phone *

Emergency Contact #2

Name

Address

City

State/Province

Zip/Postal

Home Phone

Work Phone

Mobile Phone *

Employment and Income

Source of Income

Identify your current source of income and amount of monthly income.

Current Employer / Supervisor

Address

Phone

Number of Hours Worked Weekly

Current Employer / Supervisor (2)

Address

Phone

Number of Hours Worked Weekly

Past Employer / Supervisor

Address

Phone

Number of Hours Worked Weekly

Do you consent to our contacting your current employer, if any, only to verify income?

Yes

No

Criminal Conviction History

A criminal background check may be conducted for all applicants. Have you been convicted of a crime or offense greater than a misdemeanor?

Yes

No

If yes, please identify the dates of all convictions and the crimes convicted of:

If you are on probation or parole, please provide date began and when this condition is completed:

Please provide probation or parole officer name & contact information for verification:

House of Hope Foundation Recovery Residence Protocols

Do you voluntarily agree to refrain from using alcohol and any illegally controlled substances, narcotics, marijuana and alcohol while residing at the home?

Yes

No

Do you agree to random drug testing to confirm your commitment to sobriety in the recovery residence?

Yes

No

Do you agree to the following additional elements of the House of Hope Foundation residences? Check the box if you agree.

Quiet time of 10:00 pm Sunday through Thursday for sufficient rest for work, volunteering or school and 12:00 am (midnight) Friday and Saturday.

Maintaining custody and control of all medications that are legally prescribed to you.

Guests, including family members, may not spend the night at the home.

The possibility of having to change bedrooms due to new residents coming to House of Hope.

The House Rules provided to you for review during your interview.

By clicking submit you are providing your signature that all of the information provided is accurate. If accepted as a residence, you will be asked to physically sign this form.