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House Amenities
Rules and Regulations
- Financial Responsibility
  - Newcomer Packet
  - Best Practices
Apply Today

Home
About Us
House Amenities
Rules and Regulations
- Financial Responsibility
  - Newcomer Packet
  - Best Practices
Apply Today

Submit Application

Click here to download the application

Name *

First

Last

Present Address *

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth *//

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 meetings do you now attend each week? *

Do you want to stop drinking alcohol and using addictive drugs? *

Yes
No

Are you employed? If yes, who is your employer? *

Yes
No

Who is your employer?

Are you getting welfare or other non-job related income? If yes, what? *

Yes
No

What non-job related income?

If you do not have a job, will you get one? *

Yes
No

What job plans do you have?

What is your monthly income right now? *

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

What is your marital status? *

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 and reason the drug has been 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.

Have you ever lived in a Sobriety Living House before? *

Yes
No

If yes, provide the name and location.

If you answer to the previous question was "yes", finish this sentence: I left the Sobriety Living House due to ...

Relapse
Voluntarily
Other

Other:

Emergency Telephone Numbers *

List a family doctor, if you have one, plus two family members or friends. Include name, relationship, and telephone number.

I realize that the Aspen Ridge Home to which I am applying for residency prohibits all residents from using any alcohol or illegal drugs, expels any resident who violates such prohibition, equally share household expenses including the monthly rent payment, among all residents, and utilizes democratic decision making within the group including inclusion in and expulsion from the group. In accepting these terms, the applicant understands that these conditions are different than the normal due process afforded by some local landlord-tenant laws. I have read all of the material on this application form including the limitations set forth. I have also answered each question honestly and want to achieve comfortable recovery from alcoholism and/or drug addiction without relapse. *

Yes
No

Any additional, relevant information?

I have read all of the material on this application form including the limitations set forth in item 26. I have also answered each question honestly and want to achieve comfortable recovery from alcoholism and/or drug addiction without relapse.

Sign and date the above field.

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