B.Riley Sober House
Home
Services
About
Updates
Contact
HALF-WAY HOUSE
Three Quarter Living
We are currently accepting applications for Three-quarter living House. Anyone applying to live in the house is required to submit this completed application prior to interviewing. YOU must be clean & sober a Minimum of 30 days or successfully have completed a residential treatment program/half-way living program that was 30 days or longer with evidence of participation Or have a recommendation from a detox center that this level of care (placement) is right for you! A minimum payment of $360.00 is required to move-in and an additional $40.00 the Friday following move-in. (total rent is ($400) that includes all utilities).
Personal Information:
*
Indicates required field
Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
Current living situation
*
In your own words, explain current living situation
Sexual Orientation
*
Gay
Lesbian
Bisexual
Queer
Heterosexual
Asexual
Questioning
We have a 0% tolerance for discrimination or prejudice toward gender identity and sexual orientation.
What are your pronouns
*
She/Her/Hers
They/Them/Theirs
He/Him/His
Martial Status
*
Single
Married
Partnered
Divorced
Widowed
Significant Other
Prefer not to answer
Email
*
Gender
*
Female
Male
Transgender Male
Transgender Female
Gender Fluid
Agender
Non-Binary
We have a 0% tolerance for discrimination or prejudice toward gender identity and sexual orientation.
Own a vehicle
*
Yes
No
Utilize drop down box
Year/Make/Model
*
Valid drivers license
*
Yes
No
Utilize drop down box
Driver's License Number
*
Recovery Information:
Do you indentify as
*
Alcoholic
Drug Addict
I Don't Know
Date of last of use
*
Drugs of Choice
*
Currently/recently in treatment? Yes/No
*
Yes or No answers please
Name & location of facility
*
Did you complete successfully? Yes/No
*
Discharge Date
*
Name & number of counselor
*
How do you plan on staying clean and sober?
*
Do you attend 12-step meetings
*
Yes
No
Not my thing
Who referred you to B. Riley 3/4 living?
*
Do you have a sponsor? Yes/No
*
Have you ever lived in recovery residence? Yes/No
*
Name and location of house
*
Why do you want to live at B. Riley Recovery House?
*
Employment information:
Are you employed?
*
Yes
No
Actively seeking Employment
If yes, name and location of employer
*
Current monthly income
*
What other types of work have you done?
*
Special Skills/Trainings
*
If no, how long since last employed?
*
Are you willing/able to get a job within 30 days?
*
Are you willing/able to be self-supporting?
*
Will someone else be helping you pay rent of depost?
*
Name
*
First
Last
[object Object]
Phone Number
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Legal Information:
List pending charges/cases/warrants
*
Currently on probation or parole
*
Parole
Probation
Inactive Probation
No parole or probation
Probation/Parole officer name and number
*
Are you a registered sex offender?
*
Have you been convicted of arson?
*
Medical Information
List all medical/psychiatric conditions
*
List all current medications
*
Describe any injuries or disabilities
*
Are on on medically-assisted treatment
*
Suboxone
Methadone
Vivitrol
None
Emergency Contact:
Name at least two
Name
*
First
Last
Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
Relationship
*
Phone Number
*
Relationship
*
Submit
Home
Services
About
Updates
Contact
HALF-WAY HOUSE
Three Quarter Living