Sober Living with Oxford House

Which location are you applying to?*
- Men's St George
- Women's St George
- Men's Cedar City
- Women's Cedar City
Today's Date*
Date Format: MM slash DD slash YYYY
Name*
First Last
Phone Number*
Email*
Driver's License Number*
Date of Birth*
Date Format: MM slash DD slash YYYY
Age*
Current Address*
Street Address Address Line 2 City State ZIP Code

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Have you ever been convicted of a felony?*
Explain
Are you currently working?*
If yes, who do you work for?
I am currently working*
- Full-Time
- Part-Time
- Actively looking for employment
How do you plan to pay for sober living?*
- Cash
- Check
- Parent/Spouse
- Ecclesiastical Support
- Other
Explain
What is your highest level of education?*
What is the name of that school or institution?*
Emergency Contact Name*
First Last
Emergency Contact Phone*
Emergency Contact Email*
Emergency Contact Address*
Street Address Address Line 2 City State ZIP Code

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Personal Reference 1 Name*
First Last
Personal Reference 1 Relationship to you*
Persona Reference 1 Phone Number*
Personal Reference 1 Email*
Personal Reference 2 Name*
First Last
Personal Reference 2 Relationship to you*
Personal Reference 2 Phone Number*
Personal Reference 2 Email*

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Why are you interested in recovery?*
Do you want to be sober?*
- Yes
- No
- Undecided
What treatment(s) have you attended? (Choose all that apply)*
- Residential (Inpatient)
- Day Treatment (PHP)
- Intensive Outpatient (IOP)
- General Outpatient (GOP)
List names & dates of treatment episodes
Are you currently seeing a therapist/counselor?*
Explain
Are you currently attending any 12 step meetings?*
Are you currently working with a t 12-step sponsor?*
Are you currently taking any prescriptions?*
If yes, list all medications and dosages.
Drug(s) of choice*
Longest period of sobriety*
Date of last use*
Date Format: MM slash DD slash YYYY
Do you have a history of abusing inhalants?*
Do you have any medical, health, or dietary issues we need to know about?*
Explain if the answer is yes
Federal Anti-Drug Abuse Act
I realize that the Access Foundation House to which I am applying for residency has been established in compliance with the conditions of § 2036 of the Federal Anit-Drug Abuse Act of 1998, P.L. 100-690, as amended, which provides that federal money loaned to start the house requires the house residents to (A) prohibit all residents from using any alcohol or illegal drugs, (B) expel any resident who violates such prohibition, (C) equally share of household expenses including the monthly lease payment, among all residents, and (D) utilize democratic decision making within the group including inclusion in and expulsion from the group. In accepting these terms, the applicant excludes himself from the normal due process afforded by local landlord-tenant laws.
Agreement*
- I have read and agree to the item above
Submission
I have read all of the material on this application form including the limitations set forth above in the Federal Anti-Drug Abuse Act of 1998. I have also answered each question honestly and want to achieve comfortable recovery from alcoholism and/or drug addiction without relapse.
By submitting this form you agree to all of the above and affix your signature in confirmation.
Email
This field is for validation purposes and should be left unchanged.

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