Application Full Legal Name (middle name required) * Current Address * Phone (###) ### #### Email * Birth Date * MM DD YYYY Emergency Contact * Have you previously lived at Accountable Guys? * YES NO If Yes, When? If yes, which location? Are you currently living in a Sober House? * YES NO Current Sober House If yes, which location? Date Housing Is Needed? * MM DD YYYY What is your Drug Of Choice? * Date Of Last Use? * MM DD YYYY Are you prescribed Suboxone? * YES NO Are you prescribed Methodone? * YES NO If yes, which clinic is your prescriber at? Are you currently enrolled in a Treatment Program? * YES NO If yes, what location? Current Mental Health Diagnosis * Current Medications you are prescribed * Are you currently Employed? * YES NO If yes, where? List any Criminal Convictions * Are you currently on either Probation/Parole? * YES NO Probation/Parole Contact Information Are you currently on a Civil Commitment? * YES NO If yes, which County? Commitment Case Manger Contact Information By checking ALL boxes below, I understand the following rules and expectations of The Accountable Guys Sober Housing Program. Upon acceptance into our Housing Program I agree to following and meet all rules and expectations. YOU MUST CHECK ALL BOXES BELOW TO APPLY. * I will agree to sign a release of information to the above noted individuals I will stay medication compliant at all times and notify management of any changes If Applicable, I agree to pay my monthly rent on the first of every month I agree to remain clean and sober at all times By accepting residence at The Accountable Guys I will follow all rules and regulations By accepting these terms I understand that I exclude myself from the normal due process afforded by local landlord/tenant laws By submitting this application, I certify that all information I provided is correct. I have read all materials on this application including the limitations above. I have answered each question honestly and want to achieve a life of sobriety, free from drugs and alcohol. Thank you!We will reach out to you shortly regarding your application.If you do not hear from us within 24hrs, feel free to give Tom Geiselhart a call.