Bridge House Housing Application

Application for Housing at The Bridge House

All information is held in strictest confidence. At no given point is information disclosed or shared without client’s written consent.

Please note that all information marked with an * must be completed or you will not be able to submit the application online.

Full Name*

First NameMiddle NameLast Name

Date*

Date

Social Security Number*

Numbers only - no dash

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Birth Date*

MonthDayYear

Cell Phone Number*

Fill in with 000-000-0000 if not applicable.

Work Phone Number*

Fill in with 000-000-0000 if not applicable.

Home Phone Number*

Fill in with 000-000-0000 if not applicable.

E-mail*

Fill in with none@none.com if you don't have one.

Which Bridge House are you applying to?

What is your current living situation?*

Type your answer

What is your marital status?*

Choose one answer from the drop-down list.

Are you a recovering:*

AlcoholicDrug AddictNeither

Date of last drink or drug usage:*

Give at least month and year.

Are you currently in treatment?*

YesNo

Type of Treatment:*

In-patientOut-patientNone

If you are in treatment, where?*

Type none if not applicable.

Date Entered Treatment?

How many NA, HA, AA, CA or Celebrate Recovery meetings do you attend each week?*

Have you ever lived in a recovery house before?*

YesNo

If yes, give name of recovery house, city and state.*

Type none if not applicable.

Did you leave on good terms?*

YesNo

What is your monthly income from all sources?*

Are you currently employed?*

YesNo

If not employed, are you willing to get a job?*

YesNo

Do you receive any income from the following (choose all that apply):*

WelfarePensionChild supportOther

Are you currently on probation or parole?*

YesNo

If yes, who do you report to?*

Give full name of officer and phone number.

Do you have any lawsuits pending?*

YesNo

Do you have any outstanding warrants?*

YesNo

Do you have a valid driver's license?*

YesNo

If yes, what state is it issued in?*

.

Provide driver's license number.*

.

If your application is accepted for interview process, do you give consent for a background check to be conducted?*

YesNo

Are you under a doctor's care?*

YesNo

If yes, what for?*

Provide names of all conditions for which you are under a doctor's care.

Are you currently taking prescription medications?*

YesNo

List medicine name, how much you're taking and when:*

What is your doctor's name?*

Give full name.

Doctor's Phone Number*

Area CodePhone Number

What is the date of your last T.B. test?*

Give at least month and year or state 'don't know'..

Are you currently experiencing any physical disability?*

YesNo

If yes, are you under a doctor's care for the disability?*

YesNo

Is there a family history of mental illness?*

YesNo

Have you ever attempted suicide?*

YesNo

Have you ever had psychiatric placement?*

YesNo

If yes, please give explanation (include length of stay, diagnosis and treatment):*

Type none if not applicable.

Do you experience anxiety attacks?*

YesNo

If yes, please give explanation (include any professional treatment, diagnosis and symptoms):*

Type none if not applicable.

Do you experience depression?*

YesNo

If yes, please give explanation (include any professional treatment, diagnosis and duration):*

Type none if not applicable.

List two emergency contacts:

Emergency Contact #1*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Relationship*

Phone Number*

Area CodePhone Number

Emergency Contact #2:*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Relationship*

Phone Number*

Area CodePhone Number

Thank you for your application. You will be notified of the next step in this process.

The Bridge House is under the purview of Reach Network, an exempt organization as described in Section 501(c)(3) of the Internal Revenue Code; #81-4271618.

office@reachnet.work