Sharpen Recovery Application

First Name

Last Name

Who referred you to Sharpen Recovery?
Name and Phone Number

What is your gender?

Do you think you have a problem with drugs/alcohol?

YesNoUnsure

Date acceptance into a house is needed?
(MM-DD-YYYY)

Do you have a cell phone?

YesNo

What is your cell phone number?
(if you don't have a cell phone, please put N/A.)

What number should we call to respond to this application?

What is your email address?

Date of Birth
(MM-DD-YYYY)

Age?
Must be 18 to apply

What county do you currenly live in? If you are homeless, please select the County where you are located?

If your County was not listed above, please type in your County name below.

Where are you currently living?

Rehabilitation Center / Treatment CenterLiving with someoneHomelessOther

If Other was selected, please describe.

If you're currently in a Treatment Center, please select the name of the Treatment Center below. If this does not apply to you, choose N/A.

If your Treatment Center is not listed above, please type the name below.

What is your ideal Sharpen Recovery house location?

Have you applied for or been to Sharpen's program before?

YesNo

Marital Status

Do you have a vehicle?

YesNo

Are you currently employed?

YesNo

Where do you work?
If this does not apply please reply N/A

Do you consider yourself a Christian?

YesNo

Please list all convictions and date of convictions - anything on criminal record.
If this does not apply, please reply N/A.

Are you currently on probation or parole?

YesNo

Are there any warrants out for your arrest?

Yes NoUnsure

What is your PRIMARY drug of choice?

Check all of your drug/substance preferences.

Date you last used drugs or alcohol?
THE DATE YOU ENTER MUST BE BEFORE TODAY'S DATE

Do you have a history of overdose?

YesNo

If yes - when was the last time you overdosed?

Are you currently working or willing to work a program of recovery? (AA, NA, CR, etc)

YesNo

How long are you interested in being in Sharpen's program?

Where do you see yourself moving to or living after Sharpen Recovery?

What is your vision for success while at Sharpen Recovery?

Have you been diagnosed with a mental health disorder (other than substance abuse disorder)?

YesNo

Please check all diagnoses
If this does not apply please check N/A

If your diagnosis was not listed above, please type in below.

Please check all doctor prescribed medications you are currently taking.

If doctor prescribed medication was not listed above, please type in below.

Are you currently prescribed any of the below narcotics?
If not prescribed any, please select N/A

If a currently prescribed narcotic was not listed above, please list below.

Are you currently receiving disability benefits?

YesNo

Are you a veteran?

YesNo

What is your highest education level?

Is there anything that would prevent you from working a job?

YesNo

If yes to previous question, what is the reason?
If this does not apply, please reply N/A

Do you understand that Sharpen Recovery has program fees in the amount of $595-$695 per month?

YesNo

Are you able to pay at least half of one month's program fees on the day of move in?

YesNo

Will you be able to pay your program fees throughout the duration of your stay?

YesNo

Please list 2 character references.
Please list name - relationship - phone number

Is there anything else you would like Sharpen Recovery leadership team to know?