Wisdom Recovery Homes Application
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First and Last Name *
Date of Birth *
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What gender do you identify with? Please include your pronouns *
Email address
Phone number
Mailing address: *
Are you willing to commit to stay at the house for at least 4 month? *
Anticipated move in date: *
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DD
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Length of sobriety? *
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Drug of choice and preferred route? *
Alcohol or other drugs used/abused in the past 12 months: (check all that apply) *
Required
Will you be attending outpatient treatment? *
Currently employed? *
Are you capable of working or volunteering 20 hours per week? *
Who will be responsible for your monthly fee? *
Required
What medications are you currently prescribed? *Put "NA" if not applicable. *
Have you ever been convicted of a sex crime or arson? If yes, when and please briefly describe crime:  *Put "NA" if not applicable. *
Check that all that apply: *
Required
Are you willing to sign releases  of information for any person involved in recovery efforts?         (release will follow minimum necessary rule) *
Required
Name and contact information of Probation, Parole, and case managers: *Put "NA" if not applicable. *
Name and contact information of Probation, Parole, and case managers:
Do you intend to have children living with you at the sober home? *
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