Apply Name* First Last Date* Date Format: MM slash DD slash YYYY Sobriety Date* Date Format: MM slash DD slash YYYY Referred by* First Last Occupation*Phone*Email* Date of Birth* Date Format: MM slash DD slash YYYY Social Security No.*Date of Birth* Date Format: MM slash DD slash YYYY Drivers License (State)*Parole Officer/Case Worker* First Last Phone*Drug(s) of Choice*Health Information 1. Post Traumatic Stress Disorder 2. blackouts 3. Chronic nausea, vomiting 4. audio or visual hallucinations 5. anxiety 6. other nerve disorders 7. ulcers 8. stomach disorders 9. liver disorders (hep. C) 10. pancreatitis 11. bi polar disorder 12. diabetes 13. heart trouble 14. lung disorders (TB) If Other, please explainDescribe any current psychiatric disorders:Doctor*Hospital*Past psychiatric disorders:Describe suicidal history/thoughts:All current medication:All past medication:Hospitalizations:Treatment centers: where/when:Longest period of sobriety, if any:Explain why you decided to get sober now:Contact person(s):* First Last Phone*Relationship*House Rules House of Friends Note: House of Friends (HOF) is a sober living home for veterans and whose primary problem is alcohol and or drug addiction. **We do not accept sex offenders or gang affiliated individuals or individuals that have a history of violence while incarcerated. Rules: By checking each box below and signing this document you are agreeing to the conditions needed to be accepted as a resident of House of Friends.No drinking or ingesting of any non-prescription drugs* By checking this box I agree to the above rule.No smoking in the house although there is a designated area for ones that do smoke* By checking this box I agree to the above rule.House chores are divided between residence* By checking this box I agree to the above rule.9:00pm curfew Sun/Thurs, 10:00pm Fri/Sat, therefore no late evening or graveyard jobs. Note: Immediate eviction from HOF if you stay out all night.* By checking this box I agree to the above rule.You must have and AA or NA sponsor within 10 days of residence* By checking this box I agree to the above rule.Mandatory 2 outside AA/NA meetings a week/two AA/NA meetings brought into house twice a week.* By checking this box I agree to the above rule.NOTE: Outside meetings are very important. This is where we as recovering alcoholics/addicts are able to form lifelong relationships and acquire the emotional and spiritual tools needed to help us live a harmonious peaceful sober life. Residents must attend a mandatory house meeting once a week.* By checking this box I agree to the above rule.This weekly meeting has three purposes: To go over everyone’s week to see if there are any problems that need addressing. Many times when you express a concern with the group, a solution will manifest itself. To discuss any problems or concerns that you may have with your past week outside and or inside the house. For example; if you are having a problem at work, with family, staff or fellow tenants, this weekly meeting is the time to express that problem. (This also can be done privately with Charlie McGinnis). To get update on residents sponsor and what step is being studied.Breathalyzer test given every night with random UA’s throughout the week. UA’s are always given if drugs are suspected.* By checking this box I agree to the above rule.Our program suggests 6-months minimum when coming from a treatment program.* By checking this box I agree to the above rule.There is no deadline to your stay here if you are following the rules of the house. Rent is $500.00 per month. (Must be paid prior to entry) After the first month, rent can be paid one of three ways: $500.00 on the day rent is due $250.00 on rent day and the remaining $250.00 two weeks later $125.00 per week for the 1st four weeks of the new month The $500.00 includes utilities and a fully furnished house with completely equipped kitchen, laundry room, cable television and internet access. Bed linen, towels and wash cloths are also provided. The only necessities needed by the resident are toiletries, laundry detergent and food.Please verify that you have read the rules and agree to them.* I have read the above rules and agree to the conditions needed to be accepted as a resident of House of Friends Veterans’ intake formFOR VETERANS, ONLY DD2-14:YesNoWar Served in*Service Branch*Service Date from* Date Format: MM slash DD slash YYYY to* Date Format: MM slash DD slash YYYY Type of Discharge*HonorableGeneralOTHBCDDishonorableOtherIf Other, please explainHave you ever been convicted of any sex offenses?*SelectYesNoAn answer of yes means that you will not be accepted into HOF.Are you on parole?*SelectYesNoAn answer of yes means that you will not be accepted into HOF.Do you have a history of violence while incarcerated?*SelectYesNoAn answer of yes means that you will not be accepted into HOF.Are you or have you been gang affiliated?*SelectYesNoIf you are no longer gang affiliated, you may still be accepted into HOF.Are you still gang affiliated?*SelectYesNoAn answer of yes means that you will not be accepted into HOF.Date that you dissolved your affiliation:* Date Format: MM slash DD slash YYYY Gang name:*Incarceration HistoryPrisonStateIf New Mexico, NMDC #Date of IncarcerationDate of ReleaseOffender Prisoner #Reason for Incarceration We need both prison and jail incarcerations. This section is for prison name and dates incarcerated. The next section is for MDC [jail] & other institutions. Click the plus symbol to add more entries.Metropolitan Detention Center/Other HistoryDate of IncarcerationDate of ReleaseReason for Incarceration This section is for MDC [jail] & other institutions. Click the plus symbol to add more entries.