| Application for Residence Albert House Inc., 119 Grove St., Torrington, CT 06790 Sober Living for Men Office phone/fax 860-201-5000 Please print… 1.) Your Name__________________________________ Date________________________ 2.) SSN_____-____-__________ age_________ 3.) Next of kin________________________________________ Telephone#_____________ Address_____________________________________________________________ 4.) Current treatment provider, if any.(ie. Rehab, outpatient,etc): Place Name________________________ Address_________________________________ Counselor_______________________________ Telephone #_________________________ 5.) Estimated move in to Albert House Date____________________ 6.) Date of Recovery_________________ Addictions_____________________________________ 7.) Are you on probation? Yes____ No____ Any outstanding warrants ? Yes___ No___ 8.)Do you have a job? Yes____ No____ 9.) Will you be willing to work for minimum wage in order to pay rent? Yes____ No____ 10.) Are you willing to go to any lengths to stay sober? Yes____ No____ By signing this form ,I understand that I voluntarily forfeit any and all tenant/landlord rights I may or may not have, and that I will vacate the premises immediately if I am found to be in the possession of ,or under the influence of alcohol or drugs. I also understand that my personal belongings will be stored for a maximum of 24 hrs from the time I am asked to leave and then will be given to Good Will. Signed____________________________ Date______________ Albert House Inc. is a DMHAS Certified CT Sober House and a 501(c)(3) Public Charity as determined By the IRS |
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