VOH Admission Application

Personal Information
Full Name*

First NameLast Name
Birth Date*

MonthDayYear
E-mail*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*

Area CodePhone Number
How were you referred to us? *
Employer*
Occupation*
Emergency Contact*
Emergency Contact Phone Number*

Area CodePhone Number
Last Four digits of SSN:*
Personal History
Are you taking any medication, if yes, please list them.
List any medical problems or mental health conditions:
Date of Last Use*

MonthDayYear
Date
Primary Substance Abused*
Age Started *
Do you have experience with Alcoholics or Narcotics Anonymous? *

YesNo
Do you have a sponsor?*

YesNo
Have you ever worked steps?*

YesNo
Have you ever been arrested?*

YesNo
If so, what City, State(s)?
Are you on parole or probation?*

YesNo
If so, what is your officer's name?
Have you ever lived in a recovery, sober living or transitional house or received drug/alcohol treatment?*

YesNo
If so, where and how long?
Do you have a Driver's License?*

YesNo
If no, do you have and valid Florida ID?*

YesNoN/A
Do you have a car?*

YesNo
If so, does it have valid registration and insurance?*

YesNo
Do you have a cell phone?*

YesNo
Do you typically get emails to your phone?*

YesNo
Do you have your own clothes and hygiene items?*

YesNo
Do you agree to the Rules listed on the Rules Page?*

YesNo
Do you have the funds to move in?*

YesNo
Why do you want to live in a recovery home? *
Please describe how you believe Vision of Hope can help you? *
If accepted, what goals do you hope to reach within the next six months? *
Do you have any questions about the rules or the program? *
Signature and Submission
Signing this form below means you agree to follow all the rules of our program and understand violation of the rules may result in discharge from the program.
Signature

Clear
Date*

MonthDayYear
Should be Empty:

Personal Information

Personal History

Signature and Submission