Transitional Living Application

Thank you for your interest in Herron Solutions Transitional Living.

Please take your time as you answer all questions completely.

When finished make sure to click on the submit button.

First name

Last name

Phone Number (Entering phone number and submitting application, allows for calls and texts related to employment)

Birthday

Month

Day

Year

What is your drug(s) of choice?

How long have you used substances?

Have you ever been to rehab/detox?

Have you attended any programs that have helped in the past?

What do you think a sober living house is for?

Describe your past and current living situation?

What motivated you to want to participate in this program?

What plans do you have for your recovery?

What support do you plan to receive from our program?

Are you currently on probation or parole?

Have you ever been charged or convicted with a sex crime? If so, please elaborate.

Do you have any children?

What is your current relationship status?

What supports do you have in place right now?

Please list all medical diagnosis

Please list all mental health diagnosis

Please list all medications with dosage and frequency

Is there anything else you would like us to know about you?

Please check all that apply:

I acknowledge that I have read the Policy & Procedures.

I understand and agree to all Policy & Procedures

I have questions about Policy & Procedures

By signing below you agree that all information is true and correct to the best of your knowledge.