Four County Transitional Living

Application Form

Enter your information as thoroughly as possible in the form below, then hit submit to apply for residency. Note:Fields Marked with Are Required

Your details

Name
Please enter your full name
Date of Birth
Please enter your date of birth as mm/dd/yy
Address
Please enter your full address, with apt #
City
Please enter your city
State
Please enter your state
Zip Code
Please enter your zip code. 5 numbers optionally followed by an additional 4 numbers; either 12345 or 12345-1234.
Phone Number
Please enter your Phone Number e.g. 123-123-1234.
Email
Please enter a valid email address e.g. name@example.com

Current Condition Information

What are your goals while living at 4CTL?
What do you hope to achieve?
Have you been clean and sober for at least 72 hours? Yes No
Please click yes or no
Are you addicted to Alcohol?
1. Yes No
2. Date of last drink
  Please enter your date of your last drink in mm/dd/yy format

Are you addicted to Drugs?

Yes No
Date of last use
Please enter your date of your last drug usage in mm/dd/yy format
Ever attend Alcoholics Anonymous or Narcotics Anonymous?
Yes No
Do you have a sponsor? Yes No
If so, who?

Legal Questions Section

Are you involved in any legal action at this time? Yes No
Are you currently on probation? Yes No
Is your stay here, if approved, going to be under court order? Yes No
If yes, what date is the court order obligation satisfied on?

Please enter your date of your court order obligation completion in mm/dd/yy format
If you answered yes to either of the above questions, please explain the circumstances in detail:

Commit to Recovery Section

Have you made a commitment to stop drinking and /or using drugs? Yes No
Who are you making the commitment to stop?
Are you willing to commit to stay at 4CTL for 270 days? Yes No
Who referred you to Four County Transitional Living?
Have you ever lived in a recovery house? Yes No
Where?

Employment and Financial Section

Are you employed? Yes No
If employed: where?

If unemployed: are you willing to get a job? Yes No

What are you qualified to do and what do you want to do? Be specific! For example, do not answer “Construction” if you are a plumber or electrician. List what you are qualified to do or have an interest in doing:

Do you receive unemployment, disability, pension or any other income Yes No

Sources:

Amount per month:

Current Monthly Income Sources
What do you expect next month?

Emergency Contacts
Please list two (2) people to contact in the case of emergency:

First Emergency Contact
1. Name
  Enter full name of first emergency contact
2. Address
  Enter address of first emergency contact
3. Relationship
  Enter relationship of first emergency contact
4. Phone
  No spaces or brackets e.g. 123-123-1234
Second Emergency Contact
1. Name
  Enter full name of second emergency contact
2. Address
  Enter address of second emergency contact
3. Relationship
  Enter relationship of second emergency contact
4. Phone
  No spaces or brackets e.g. 123-123-1234
Physician's Information:
1. Name
  Enter the name of your of your primary physician
2. Address
  Enter address of your primary physician
3. Phone
  No spaces or brackets e.g. 123-123-1234
List any additional information that would be helpful for us to know during your stay:

Read the House Rules by Clicking Here

I HAVE READ AND UNDERSTAND THE HOUSE RULES AS STATED ABOVE AND AGREE TO COMPLY AS A CONDITION OF MY ADMITTANCE.
FOUR COUNTY TRANSITIONAL LIVING ENFORCES IMMEDIATE EXPULSION IF ANY RESIDENT IS:
- Found to be using alcohol or drugs.
- Is non-compliant with the House Rules.
I agree with all of the above statements, I waive any Resident rights while an occupant at Four County Transitional Living, Inc.

I agree that 4CTL or its agent may use the above information for a background check.
Your Signature
Current Date