Horizon House Sober Living — Member Application

📋 Please Be Honest

Your answers help us determine the best path for your successful recovery. This information is used to support you, not to disqualify your acceptance. Honesty allows us to provide the most appropriate care and environment for your journey.

Personal Information

First Name

Last Name

Address

City

State

ZIP

Gender

Male Female Other

Date of Birth Driver’s License Number State Vehicle Make & Model Cell Phone Email Desired Move‑In Date Why are you seeking sober living at this time? Referred By Referral Phone

Treatment & Transition

Detox Completed?

Yes No

Inpatient Completed?

Yes No

Total Days Treatment Facility Facility Phone Attending IOP?

Yes No

If yes, where? Do you have a job?

Yes No

If yes, where? IOP / Work Schedule Drug(s) of Choice Sobriety Date Are you regularly attending recovery meetings (AA, NA, Smart Recovery, etc.)?

Yes No

Do you have a sponsor?

Yes No

If no, are you willing to get one?

Yes No N/A (I have a sponsor)

Sober Living History

Is this your first time in sober living?

Yes No

If no, how many sober living homes have you previously stayed in? Have you ever been asked to leave a treatment facility or sober living house?

Yes No

If yes, please explain the circumstances

Legal Status

Are you a 290 PC registrant?

Yes No

Currently on probation or parole?

Yes No

Any legal matters pending?

Yes No

If yes to any, provide details

Medical Information

Current Medications Medical / Mental Health Conditions or Allergies

House Responsibilities

Are you willing to do daily chores and help keep the house clean?

Yes No

Are you willing to follow a structured daily schedule which includes meetings, work or school, chores, accountability, random drug testing, and abiding by house rules and expectations?

Yes No

Emergency Contact

Name Relationship Phone Email

Certification

Name (Typed Signature) Date

⚠️ Staff Approval Required

This application will be reviewed and approved by Horizon House staff before being processed. You will receive confirmation once approved.

✓ Thank You for Your Interest in Horizon House!

Your application has been submitted and will be reviewed by our admissions staff.

We will be in contact with you shortly.

Should you have any questions or need additional information, please call us:
(760) 766-0300

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