Sober Living Application

RESIDENT APPLICATION

Tell us about yourself.

We’ll use your answers to review your housing application and follow up about practical needs. Optional treatment and medication details do not by themselves decide admission.

01About you

Legal name

Name you prefer to use

Date of birth

Phone number

Email address

Best way to contact you

Current address or facility (street, city, state, ZIP)

May we leave a message?

02Housing request

When do you need housing?

Requested move-in date

Why are you seeking recovery housing now?

Who referred you? (name, organization, phone)

03Recovery housing eligibility

A yes answer does not automatically result in denial unless it concerns a basic house requirement. If you may need urgent medical care or detoxification, seek medical help before moving in; call 911 for an emergency.

Do you voluntarily want to live in an alcohol- and drug-free recovery residence?

Date of last alcohol use (or Never)

Date of last illegal or nonprescribed drug use (or Never)

Substances used during the past 12 months, including alcohol and misuse of prescriptions (or None)

Are you experiencing or expecting withdrawal symptoms that may require medical attention?

If medical withdrawal management was recommended, have you completed it or received medical clearance?

Do you understand that Second Harbor does not provide medical detoxification or 24-hour clinical supervision?

Are you participating in treatment, counseling, or peer recovery support?

Have you been to rehab or substance-use treatment before?

This includes detox, residential rehab, and outpatient treatment. Your answer alone does not decide admission.

If yes, what type of program and about when?

You may answer here or discuss it privately. Do not include diagnoses, treatment records, or discharge summaries.

Current recovery support or program you want us to know about

Optional. We will request a separate authorization before contacting a treatment provider.

Recovery meetings or other supports you use

Peer groups, faith community, sponsor, or recovery coach.

Your plan for maintaining recovery while living at Second Harbor

04Previous housing, income & supervision

Do not enter bank-account or benefit-claim numbers.

Have you lived in a sober-living or recovery residence before?

If yes: residence name, location, approximate dates, and reason you left

Do you have an unresolved financial or property obligation to a prior residence?

If yes or unsure, explain the status and your plan to resolve it

Current primary income source

Employer or income source and contact information, if available

Approximate monthly income available for housing

Can you pay the move-in amount and ongoing housing fee?

Employment or payment plan for the next 30 days

Are you under probation, parole, pretrial release, or another court supervision?

If yes: supervising agency, officer, and phone

Could a court order, registration requirement, or geographic restriction affect where you may live?

If yes or unsure, explain what we need to know to evaluate placement

05Medication, accommodations & safety

Second Harbor provides shared housing, not medical care or medication management. Lawfully prescribed medication, including medication for substance-use disorder, does not by itself disqualify you. You may discuss medication details privately during a follow-up conversation.

Are you currently taking any medications?

What medications are you currently taking?

If yes, list the names here or discuss them privately before move-in. Do not include diagnoses, treatment records, or the reasons for prescriptions.

Do you need a reasonable accommodation or modification to apply or live in the home?

If yes: describe the change you need, not your diagnosis

Would you like to discuss secure medication storage or access in the home?

Is there a practical support or arrangement you want to discuss before moving in?

Optional. You do not need to disclose a diagnosis.

If you are in immediate danger, call 911. For a mental-health crisis, call or text 988. This form is not monitored for emergencies.

06Emergency contacts

At least one contact is required. We will not use these contacts to verify treatment information without appropriate authorization.

Emergency contact name

Relationship

Phone number

Alternate phone or email

Second contact name

Relationship

Phone number

Alternate phone or email

08Applicant statements & signature

My information is true and complete to the best of my knowledge; material false statements may affect admission or residency, subject to law.Second Harbor may contact the nonmedical references, recovery residences, employers, income sources, or supervision contacts I listed solely to evaluate my application. Protected health or treatment information may need a separate release.Submitting this application does not guarantee admission, reserve a bed, or create a lease, license, tenancy, or resident relationship.Second Harbor may request an interview or additional documents reasonably related to admission, identity, payment, safety, or accommodations.Use or possession of prohibited substances or drug paraphernalia, or medication misuse, may result in termination and removal under the resident agreement, policies, and applicable law.Second Harbor is not a medical provider; I am responsible for obtaining, storing, and taking medication as directed, subject to policy and any approved accommodation.Background screening or a consumer report requires my separate authorization below and does not include medical or treatment records.I consent to electronic records and signatures for this online application and may request a paper copy.

Type your full legal name as your electronic signature

Date signed

Best time for an interview

09Separate background-screening authorization

Second Harbor Holdings LLC may obtain tenant-screening or consumer reports to evaluate this application. Reports may include identity and address verification, criminal history, sex-offender registry information, eviction and rental history, and credit history only if Second Harbor elects to use it. This does not authorize access to medical or substance-use treatment records.

I authorize Second Harbor Holdings LLC and its screening provider to obtain and review that information solely for this application. Courts, public-record custodians, prior landlords, property managers, references, and other lawful sources may provide relevant information. This does not guarantee admission. Do not enter a full Social Security number; a screening provider will request it securely if needed. If a consumer report leads to adverse action, Second Harbor will provide notice required by law.

Other names or aliases used

Previous address (if current address is less than three years old)

I have read this separate disclosure and authorize the background screening described above.My identifying information is true and complete. An electronic or copied authorization may be used as if it were the original.

Type your full legal name to sign this separate authorization

Date signed

By selecting Submit, you consent to send this application as a PDF attachment to Second Harbor for review. Please do not include a full Social Security number, bank details, or uploaded records anywhere in your answers.