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Woman Application

If you are applying for you and your child(ren), you must fill out child application in order for your application to be complete. 

Name (First, Middle, Last)*

Date Of Birth *

Age*

Phone*

Email Address*

Marital Status

Current Living Situation*

Current Address*

City*

State*

Zip Code*

Own A Vehicle? *

Year/Make/Model

Tag #

Valid Driver's License*

State

Driver's License/ or ID #*

Are you an alcoholic? *

Date Of Last Use*

Drug(s) of Choice*

Currently/recently in treatment? *

Name & Location of Facility

Did you complete successfully? *

Discharge Date

Name Of Counselor

How do you plan to stay clean and sober? *

Who referred you to Secrets Of The Heart Transitional Living, LLC.? (Name, Relationship, & Phone) *

Do you attend 12-step meeting? *

If so, how often?

Do you have a sponsor? *

Have you lived in a recovery house before? *

Name & Location of House

When/how long?

Why did you leave there? *

Why do you want to live at Secrets Of The Heart Transitional Living, LLC.? *

Are you employed? *

If Yes, Name & Location of Employer

Job Title

How Long Employed?

Current Monthly Income *

What other types of work have you done?

Special Skill/Training

If No, How long since last employed?

Are you willing/able to get a job within 14 days? *

Are you willing/able to be self supporting? *

Will someone else be helping you pay rent or deposit? *

Name/Relationship

Phone

Street Address

City

State

Zip Code

List Pending Charges/Cases/Warrants*

Ever been incarcerated?*

When/How Long?

Reason

Name & Location of Facility

Currently on probation/parole? *

Location of Office

Name of Officer

Phone

Are you a registered sex offender? *

List all medical/psychiatric conditions*

List all current medications*

Describe any injuries/disabilities *

Describe physical limitations resulting from disabilities *

Name of Physician

Are you receiving Suboxone, Subutex, Methadone, Vivitrol, etc? *

Physician Prescribing

Emergency Contact Name 1*

Relationship*

Phone *

Street Address

City *

State *

Zip Code

Emergency Contact 2*

Relationship*

Phone *

Street Address

City*

Zip Code

Please be sure to shedule a zoom interview under the sober living application tab and your check your email for all communications concerning any denials, approval of zoom interview with zoom link, and etc. If you have any questions, please feel free to contact the COO/Program Director at any time. Thank you!

Secrets Of The Heart Transitional Living, LLC. 

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