If yes, What drugs have used in the past 3 years?
If yes, What Rehab have you been to and where is it located?
Date of last drink or drug?
When did you attend your first A.A. or NA meeting?
How many meetings do you attend per week?
Do you want to stop drinking & using & stay stopped?
Reminder: We will keep confidential and not release the following financial and employment information, but we need it to evaluate your ability to pay your weekly share.
Are you currently employed?
If yes, List your current employer.
What and how much is your current source of income?
Marital status: (single, separated, or divorced)
Do you currently take or need prescription drugs?
If yes, Explain what drugs and reasons.
1. Have you ever been arrested?
2. Do you have a court case pending?
3. If yes to # 2, when is your court date and what is the charge and date of charge?
4. How many times have you been arrested?
5. What was/were the charge(s)?
6. Have you ever been convicted of a misdemeanor?
If yes, Explain
7. Have you ever been convicted of & felony?
8. Are you on probation?
Are you on parole?
If yes, please list why and your probation officer's name, county and phone#:
9. Are your probation/parole fines and fees current?
10.How much are your fines and fees? $
11. Do you have any warrants for your arrest outstanding?
If yes, explain.
12. Have you ever been arrested or convicted as a sex offender?
Reminder: We will not release and keep confidential the fore going statements.
I have read the item above and by typing my ssn on this page is considered a digital signature and understand that if accepted in HAVEN HOUSE, I agree and subject myself to all rules and regulations both present and future including the waiver of any landlord-tenant rights I might have as respect to residency in HAVEN HOUSE. Deposits will not be refunded if an individual is required to leave. If leaving is voluntary and two weeks notice is given at a weekly meting, the security deposit is usually refunded within two weeks or after appropriate deductions are made. The nature of HAVEN HOUSE requires expulsion, without notice or refund of security deposit, of any resident who is found to be using either alcohol, drugs or both.
IF ACCEPTED YOUR SIGNATURE WILL BE REQUIRED AGAIN UPON ARRIVAL!ENTER YOUR SSN