Admission Document

1. General Information

First Name *

Middle Name

Last Name *

Preferred Name

Date of Birth *

Phone Number *

Email Address *

Current City / State *

Desired Move-In Date

2. Current Situation & Referral

Where are you currently living? *

Treatment / Recovery Correctional / Reentry Family / Friends Temporary Housing Unhoused Other

If Other, please explain:

How did you hear about Belles? *

Referral Organization / Contact, if applicable

3. Employment & Financial Information

Are you currently employed? *

Yes No

Employer / Source of Income

Approximate Monthly Income

Other Monthly Income

Available Savings

Approximate Total Monthly Expenses

4. Emergency & Health Information

Emergency Contact Name *

Relationship *

Emergency Contact Phone *

Do you have any allergies or dietary restrictions? *

Yes No

If yes, please provide details:

Do you have any chronic medical issues Belles should know about? *

Yes No

If yes, please provide details:

Do you have any special medical equipment? *

Yes No

If yes, please describe:

Are you currently experiencing any of the following symptoms? *

Fever Dry Cough Flu-like Symptoms None

5. Resident Suitability & Shared Living

Can you walk independently? *

Yes No Sometimes

If No or Sometimes, please explain:

Can you participate in household cleaning and chores? *

Yes No

If No, please explain:

Can you bathe and dress yourself? *

Yes No

If No, please explain:

Do you bathe every day? *

Yes No

If No, please explain:

Do you have any issues with bladder control? *

Yes No Sometimes

If Yes or Sometimes, please explain:

Are you on probation or parole? *

Yes No

Probation / Parole Officer Name:

Probation / Parole Officer Contact Number:

Supervision End Date:

Do you smoke? *

Yes No

If yes, please explain:

Are you recovering from an addiction that Belles should be aware of? *

Yes No

If yes, please explain:

What time do you normally go to bed?

Do you have any regular medical appointments? *

Yes No

If yes, please explain:

List food items you do not like

List your favorite foods

List activities you enjoy doing

List any concerns you may have living with a roommate

Do you work or volunteer anywhere? *

Yes No

If yes, please provide details:

List anything else Belles should be aware of regarding shared living

6. Applicant Certification

I certify that the information provided in this application is true and accurate to the best of my knowledge. I understand that submitting an application does not guarantee admission to Belles Clean & Sober Living.

Electronic Signature - Type Full Legal Name *

Date *

BELLES CLEAN & SOBER LIVING

1. General Information

2. Current Situation & Referral

3. Employment & Financial Information

4. Emergency & Health Information

5. Resident Suitability & Shared Living

6. Applicant Certification

Your cart is empty

Your cart is empty