Resident Application

Section 01

Personal Information

Legal Last Name

First Name

Middle Initial

Preferred Name / Nickname

Date of Birth (MM/DD/YYYY)

Age

Gender

Social Security # (last 4 digits)

Race / Ethnicity (optional)

Veteran Status

Phone Number

Alternate Phone

Email Address

Current / Last Known Address

City

State

ZIP

ID / Identification Documents Available

Section 02

Reentry & Release Information

Releasing / Released From (Facility Name)

City / State

Release Date

County of Conviction

Supervising Officer / PO Name

PO Phone Number

Parole / Probation Office Address

Supervision End Date

Case #

Current Supervision Status

Conditions of Release

Are there any conditions of release that would affect housing placement?

Yes No

If Yes, please explain

Section 03

Criminal History

Please list your three most recent offenses (most recent first). Do not omit felonies. Honesty supports your placement.

Offense / Charge	Conviction Year	Sentence	State

Sex Offender Status

Are you a registered sex offender?

Yes No

Note: Sex offender registration may affect placement eligibility based on local ordinances.

Pending Charges

Any pending charges or open warrants?

Yes No

If Yes, please describe

Section 04

Substance Use & Recovery History

Do you have a history of substance use?

Yes No Prefer not to say

Substances Used (select all that apply)

Date of Last Use

Primary Substance

Years of Use

Treatment / Recovery History

Inpatient Rehab Outpatient Treatment Detox Program Medication-Assisted Treatment (MAT) NA / AA / 12-Step None

Most Recent Treatment Facility

City / State

Completion Date

Current Medications

Are you currently on any prescribed medications?

Yes No

If Yes, list medications and prescribing provider

Sobriety Date (if applicable)

Clean Time

Section 05

Mental Health & Medical Information

Do you have any diagnosed mental health conditions?

Yes No Prefer not to say

If Yes, please list diagnosis

Do you have any physical health conditions or disabilities we should be aware of?

Yes No

If Yes, please describe

Primary Care Doctor / Provider

Provider Phone

Insurance / Medicaid #

Special Accommodations Required

Mobility / Accessibility Dietary Restrictions Visual / Hearing None

Section 06

Employment & Income

Current Employment Status

Current Employer / Business Name

Phone

Start Date

Job Title / Occupation

Monthly Take-Home Income ($)

Additional Income Sources (select all that apply)

Total Monthly Income (all sources) $

Can you pay the weekly program fee?

Yes No

Section 07

Emergency Contacts

Emergency Contact #1

Full Name

Relationship

Phone

Address

City / State / ZIP

Emergency Contact #2

Full Name

Relationship

Phone

Address

City / State / ZIP

Section 08

Personal & Professional References

Please list two references who can speak to your character and readiness for independent living. Do not list family members as references.

Name	Relationship / Title	Phone	Email

Section 09

Housing Goals & Additional Information

Desired Move-In Date

Anticipated Length of Stay

How did you hear about us?

What are your primary goals during your time at Embrace Living Solutions?

Have you ever been asked to leave a sober living or reentry program?

Yes No

If Yes, please explain

Is there anything else you would like us to know about you or your situation?

Section 10

Program Rules Acknowledgment & Agreement

By signing this application, I acknowledge that I have read, understand, and agree to abide by the rules and expectations of Embrace Living Solutions, including but not limited to:

Zero Tolerance for Substances. I will maintain sobriety from all non-prescribed drugs and alcohol. I consent to random drug and alcohol screenings at any time.
Curfew Compliance. I will comply with all curfew requirements set by the house.
Respect & Community. I will treat all residents, staff, and visitors with dignity and respect. Violence, threats, or harassment of any kind will result in immediate discharge.
Financial Responsibility. I agree to pay the weekly program fee on time. I understand that non-payment may result in discharge.
Meetings & Programming. I agree to actively participate in required meetings, case management, and any court-ordered programming.
Property & Cleanliness. I will maintain my living space and shared areas in clean condition. I will not damage property belonging to Embrace Living Solutions or other residents.
Compliance with Supervision. I will comply with all parole, probation, or other supervision requirements and keep Embrace Living Solutions staff informed of any changes.
Honesty & Disclosure. I understand that any falsification of information on this application is grounds for immediate denial or discharge.
Search Policy. I understand that my living space and belongings may be subject to inspection by staff at any time with reasonable notice.
Photo & Media Release. I understand that photos may be taken for program records. I may opt out of any public-facing media use.

Applicant Signature (Type Full Name)

Date