Safe and Sober Application — Caldwell Recovery Center LLC

DEMOGRAPHIC INFORMATION

Name

First Name

Last Name

Phone

(###)

###

####

Social Security Number

Date of Birth

YYYY

Gender (M/F)

Employed

(if no skip to the next step)

Employer

SUBSTANCE USE DISORDER

Drug(s) of Choice

Date of Last Use

YYYY

Treament Provider (if applicable)

CRIMINAL HISTORY

Have you been convicted of a misdemeanor or felony?

Will you be on probation or parole while in housing?

Probation or Parole Officer (if applicable)

First Name

Last Name

Phone

(###)

###

####

Are you involved in drug court?

Are you involved in mental health court?

Have you been convicted of a violent crime?

Are you a convicted sex offender?

If you are currently under the supervision of IDOC, please answer the following:

IDOC#

IDOC Facility

Case Manager Name

First Name

Last Name

Case Manager Email

Tentative Parole Date

YYYY

PERSONAL INFORMATION

Mental Health Diagnosis (if yes, what is your diagnosis?)

Diagnosis

Are you taking Medication? (if yes, list medication(s) below)

Medication(s)

Do you have a valid driver's license?

Do you own a car? (if yes, please answer the following)

Year/ Make/ Model

License Plate #

Color

How will you be paying your first month's rent?

Emergency Contact

First Name

Last Name

Relationship

Phone Number

(###)

###

####

Expected Move in Date

YYYY

I have read and agree to follow all Caldwell Recovery Center house rules and policies. A copy of the House Rules has been provided to me as part of this application. When I am accepted to Caldwell Recovery Center housing, and take residency, I agree to hold harmless Caldwell Recovery Center, LLC from all claims, actions and liabilities. I understand and agree that all payments to Caldwell Recovery Center, LLC are due on the 1st of every month and are non-refundable. Payments can be made by cash or money order. I have read both statements above, understand its contents, and voluntarily agree to its terms.

Application Date

YYYY