Application for Residency Last Name First Name Middle Date of Birth Social Security Number DOC Number Current Address City State Zip Current Phone Work Phone Email Address Nearest Relative/Emergency Contact Relationship Address City State Zip Phone Work Phone   Are you an alcoholic? Yes No Are you an addict? Yes No How long have you been using? What drugs have you used including alcohol? What was the longest time you were able to stay clean/sober on your own? Why do you want to get clean/sober now? Date of your last drink or drug Have you been through a Treatment Facility? Yes No Have you had any experience with AA or NA? If so, when and for how long? Are you currently employed? Yes No Employer Employer Address Phone What is the source and amount of your current income If you do not have a job, will you obtain employment immediately or go to work at a day labor pool? Yes No Marital Status Married Single Separated Divorced Do you currently take or need prescription drugs? Yes No If yes, describe List and describe any special needs, handicaps or concerns that you may have that we should be aware of regarding your residency at Harbor House I understand and agree that if accepted into Harbor House Group Recovery Homes I am subject to all rules, regulations and guidelines of Harbor House Group, Inc. I will be financially responsible for any damage to any Harbor House property resulting from my conduct or actions. Also, if I do not show up at the prearranged time of arrival, I will receive NO REFUND of any pre-paid Community Living Expenses. I Agree Yes No Full Name
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