Resident Application

Please submit your contact information and one of our associates will be in touch with you shortly.

First name

Last name

Birthday

Month

Day

Year

Phone

By providing your phone number, you agree to the Terms & Conditions of receiving text messaging and calls from our agency and third party sponsors. Your personal data is well-kept within our Data Privacy Policy.

Requested move-in date

Emergency contact name

Emergency contact number

Relation to emergency contact

How did you hear about us? Referred by? Treatment center?

Sobriety Date

Month

Day

Year

Counselor's Name

Counselor's contact

Drug of choice

Are you currently on probation/parole?

Do have you special restrictions or have to register as a sex offender?

Are you working a program of recovery? Recently graduated or looking to enroll in outpatient/after-care?

Productivity (please check all that apply)

Are you currently on any prescribed medications?

Any co-occurring issues or diagnosed mental health issues?

Why do you want to live in a sober home?

Any other requirements that you need or any concerns you would like us to know about?

Signature

Signature field is empty.

By signing this form, you understand and agree to the client (tenant)/renters agreement and any other terms that the No Luck Club Sober Living may enforce.