Temperance Sober Living Application Please enable JavaScript in your browser to complete this form.Program Eligibility Requirements Please review the following before completing this application: We do not accept any narcotic medications, including benzodiazepines, opiates, or most ADHD medications. Please disclose all current medications during your phone assessment. We do not allow medical marijuana. Applicants must be able to live independently. Applicants must be stable on medications for any mental health diagnosis. We do not accept individuals with pending charges or convictions for sex offenses. We do not accept individuals with pending charges or convictions for arson. After completing this application, please call 303-507-6858 to schedule a phone assessment. We will discuss whether our program is the right fit for you. Final admission decisions are made by the owner. If our program is not the right fit, we may provide additional recovery resources. Eligibility Acknowledgement *I have reviewed and understand the program eligibility requirements.Applicant InformationName *FirstLastDate of Birth *Phone Number *Email *Last Date of Use / Sobriety DateCurrent or Preferred Recovery Program *Most Recent Treatment Facility *Dates Attended / When were you in treatment last?Drug(s) of Choice *Employment & Financial InformationAre you currently employed?YesNoIf no, when do you expect to be employed?What financial resources do you currently have?For example: family support, job income, savings, or other resources.Do you have a vehicle?YesNoIf yes, do you have a valid driver’s license and insurance?YesNoHow do you plan on paying program fees? *Legal HistoryAre you currently on probation? *YesNoMost recent conviction, if applicablePlease explain any conviction(s), past or pendingDo you have any pending charges or convictions for arson or sex offenses? *YesNoBased on this response, Temperance Sober Living may not be able to consider you for the program.Mental Health HistoryAny history of self-harm or suicide attempts? *YesNoAny current or past mental health diagnosis? *YesNoIf yes, please explain current or past mental health diagnosisSober Living HistoryHave you been in another sober living? *YesNoIf yes, which sober living(s)?Why did you leave?Have you received a scholarship at another sober living? *YesNoMost recent scholarship, if applicableScholarship Application — OptionalTemperance Sober Living offers limited scholarships (1-8wks) to individuals who are willing to go to any lengths to get and stay sober. Scholarships are intended to provide temporary assistance and are not a permanent solution to financial need. Scholarship eligibility may be reviewed weekly and may be adjusted based on compliance with program requirements.Are you requesting scholarship assistance? *YesNoAre you willing to attend 12-Step meetings each week? *YesNoAre you willing to begin working with a 12-Step sponsor? *YesNoAre you willing to commit to 90 days at Temperance Sober Living? *YesNoWhy is receiving a scholarship important to you? *How would a scholarship benefit you?How will you pay program fees outside of scholarship funding?Additional InformationIs there anything else you would like us to know?Applicant Attestation *I certify that the information provided in this application is accurate to the best of my knowledge.Applicant Signature *Type your full legal name.Date / TimeDateTimeSubmission date is also recorded automatically by the website.Submit Application
