Tabitha’s PlaceWomen’s Sober Living HomeApplication for Resident MembershipSUBMIT BELOW OR PRINT, COMPLETE AND MAIL TO ADDRESS BELOW OR EMAIL TO: cheryl.t@newlifetreatment.com Call 507-777-4321 ext. 203 if you have questions. Name * First Name Last Name Email * Message * Date of Birth * Current Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (if you have a phone) (###) ### #### Sobriety Date * Marital Status * Single Separated Divorced Married Emergency Contact * Please include their relationship to you, their address and contact phone number. 12-Step Program History What will be your primary 12 step group? * AA NA GA Do you currently have a sponsor? * YES NO If yes, please provide the name and phone number of your sponsor. * If not, are you willing to enlist a temporary sponsor as a condition of acceptance of your membership application? * YES NO Do we have your permission to contact your sponsor in connection with this application? * YES NO Are you currently in an in-patient treatment facility? * YES NO If so, where? * Discharge Date: * Who is your counselor? * Counselor's Phone Number * (###) ### #### Counselor's Email * Do we have your permission to contact your counselor in connection with this application? * YES NO Have you received an after-care recommendation to live in a sober-living residence? Select * YES NO Has your counselor recommended Tabitha’s Place? * YES NO If you are not currently in an in-patient facility, have you ever been? * YES NO When/Where? * Did you complete treatment? * YES NO Are you willing to continue treatment; out-patient services followed by aftercare as a condition of acceptance into Tabitha’s Place? * Yes No Have you ever lived in a sober-living residence or halfway house? If so, where and for how long? * May we contact them in connection with this application? * Please provide contact infomation. Are you currently involved with the legal system in any way? * Yes No If yes, please explain: * Describe any previous arrests: * Convictions: * Are you currently under parole or suspended imposition of a sentence? If yes, please explain. * CSO or PO name and phone number: * Are you under legal obligation to report to any judicial jurisdiction your living situation? If yes, please explain. * When and for what reason were you last seen by a medical doctor? * Any hospitalizations in the last five years? If so, please describe: * Are you currently being treated for any medical condition? If yes, please describe: * Are you on any prescribed medication? If yes, please list prescriptions/dosages: * Also list any supplements you take regularly. Insurance Company and Policy Number: * *All residents who are currently taking any Prescription Medications must bring at least a 30-day supply of each medication. This is to ensure that you will have an adequate supply while you obtain a personal physician in the Woodstock area. Have you ever contemplated or attempted suicide?If yes, please elaborate: Are you currently seeing anyone for counseling, therapy, etc.? If yes, please elaborate: * Please provide the name and phone number of your therapist: May we contact your therapist in connection with this application? * Yes No Are you currently employed? . If so, where and for how long? What is your current job? * If you are currently unemployed, do you believe you will be able to find full-time employment within 45 days of beginning your residence at Tabitha’s Place? * Yes No Please list the jobs you’ve had over the last five years: * First Month Member Dues of $300.00 must be paid on or before the day of arrival. ($300.00 a month for the first 6 months $500.00 a month there after) Are you able to afford Tabitha House’s membership fees? * Yes No Maybe Do you have current or possible future financial commitments that might cause you difficulties in paying Tabitha’s Place membership fees? If so, please describe: * Is there anything else you would like us to know? * Why did you choose to inquire about Tabitha’s Place? * How did you hear about Tabitha’s Place? * MEMBERSHIP COVENANT IMPORTANT NOTICE: Tabitha House is a recovery home which may expel, without prior notice or refund of deposit and fees, any resident member who is found to be: 1) using alcohol or drugs; 2) engaging in disruptive behavior; or )3 in default of payment of monthly membership fee. All resident tenants of Tabitha’s Place, are members of our sober home. You do NOT have renter’s rights or any rights of tenants, and expressly waive any such rights in exchange for membership privileges. I have read the above notice and understand that I am applying for membership of Tabitha’s Place, as a member of this sober home. I agree to abide by the responsibilities and requirements of the house and fully subject myself to the rules of the home, which include periodic/random drug testing. I understand that I am subject to immediate expulsion from the home if any of the following occur: 1) I use alcohol or drugs (other than prescribed medications); 2) I engage in disruptive behavior); 3) I fail to pay my monthly membership fee. I understand that if I leave voluntarily and at least 30 day’s written notice is given to the house manager, my deposit will be refunded after deductions are made for any unpaid fees, damages or fines for which I am responsible. If less than 30 days’ notice is given or I am expelled from Tabitha House, I understand that my member fees will be forfeited. By signing, below or submitting this application, I certify that the information contained in this application is true. I agree that Tabitha’s Place is authorized to contact the people and places I have indicated above in connection with this application. I have read and understand the Tabitha’s Place rules and policies. I understand and accept the above condition set forth for membership at Tabitha’s Place, and agree to abide by said conditions should I be selected as a member resident. Typing my name below serves as my electronic signature. * First Name Last Name Date: * MM DD YYYY Requested Move-In Date: * MM DD YYYY Thank you!
