Greg's Place - Application
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- Dulcie Simpson
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1 Greg's Place - Application Date Name SS# DOB Age # Release / Out Date Names of next of Kin with phone numbers (Parents, Adult children, close friends) (In case of emergency) You must provide at least 4 contacts that have knowledge of your current situation and are able to contact you. yes no Are you currently involved in a relationship? Have you ended a relationship recently (within past year)? Would you like to re-join a former partner/spouse? Explain Legal Are you currently on Probation/Parole? Yes No County/ Municipality PO's Name List all Misdemeanor Criminal Convictions List all Felony Convictions 1
2 Are you currently, or when you're released, will you be on House Arrest or Bracelet Monitoring? Yes No Are you a Registered Sex Offender Yes No Violent Crime Convictions (list) Have you ever been charged with Arson *If you have answered yes to being a registered sex offender or having been charged with Arson, you will not be considered further for residence. List all children and legal guardianship Childs name Age Guardians Name Address/City/State Do you have any child support orders? Yes No Explain Do you have Child Support on the rears? Yes No How much? Employment OR Source of Income Employer Address Days & Hours Worked 2
3 Position Hourly wage $ /hour Supervisor Name How long at this company? Other Income, describe If receiving Disability or SSI, are you able to work? Vocational Information List all employment/vocations you are qualified for or have training in: Personal History NAME PHONE Drivers License # State Single Married Separated Divorced Last place of residence (besides treatment or jail) circle one parents / personal residence / significant other Street address City St Zip Do you consider yourself Alcoholic / Addict AA NA SPONSOR NAME Both NUMBER SOBRIETY DATE Drug of Choice All Drugs abused yes no Have you ever participated in 12 Step Meetings/Recovery? Have you ever had a Sponsor? What was the longest period of sobriety/clean time you've ever achieved? Was this clean time done with or without 12 Step recovery? Have you ever worked the steps of AA/NA? 3
4 Whom Referred you to Greg's Place? Medical (all information must be complete) Are you currently or have you recently received Treatment- Aftercare or other Therapy Yes Where-Provider Clinician /Therapist Other contributing Therapist (Previous diagnosis) No Medical cont'd Medical Conditions Mental Health Conditions Medications Prescribed Diagnosis Diagnosis by(dr. Name) When Where Yes/No 4
5 Current Prescriptions and Doctor prescribed by- Provide dosage amounts and times per day. Doctors name and phone number Level of Education No Diploma or GED High School Diploma GED Some College Degreed Graduate Other Have you been tested for HIV / Hep C Yes No Do you have a valid Driver's License Yes No If not- do you have a State ID? Yes No If approved for Residence to Greg's Place you will be required to provide payment for the first 3 weeks plus an entrance fee of If you are in Treatment or incarcerated at this time this amount must be paid 2 weeks in advance to hold a bed for you if one is available. I am currently of sound mind and clean from all non- prescribed drugs and alcohol and have been for a period of 72 hours. If accepted to Greg's Place for weekly residence I understand that I am agreeing to make a minimum of 5 12 step meetings a week, be actively engaged in 12 step recovery and abide by all house agreements. It is further understood that I am committing to a minimum 3 week stay. I understand that Greg's Place is a ZERO tolerance Sober Living house. I agree to never enter this house under the influence and if I relapse during my stay I agree to Immediately terminate my residence and thereby forfeit all rights to my habitation and monetary payments. Please complete and Fax or return to : Fax Wes Leibrook 216 North C Street, Hamilton, Ohio or - wleibrook@gmail.com Contact us at Cleared for residence at Greg's Place date Manager 5
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