• Application & Residential Entry Form

  • Requested Move In Date
     - -
    2 digit month, 2 digit day, 4 digit year
  •  -
  • Marital Status
  • Do You have a drivers license
  • How did you find out about Square One DE, Inc.?

  • Are you an alcoholic?*
  • Type of alcohol usage.
  • How long Have you been alcohol free?
  • Date of last drink
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you a drug addict?
  • How long Have you been drug free?
  • Date of last usage
     - -
    2 digit month, 2 digit day, 4 digit year
  • Please list any substance that you have used recreationally
  • When was your last Support Group Meeting?
     - -
    2 digit month, 2 digit day, 4 digit year
  • Have you ever been convicted of a Violent Crime or Sex Offense? *
  • Are you currently on Probation or Parole?*
  • In the past 30 days, where have you been living most of the time?
  • Are you currently employed?*
  • Are you receiving any other non-job related income?*
  • Do you need assistance in Job Searching?*
  • Please list any Job Skills that may be helpful in the Job Search process:
  • Current Education Level

  • Have you ever been in a treatment facility for drug or alcohol addiction?*
  • Configurable list*
  • Are you currently under the care of a medical professional?*
  • Configurable list
  • Please list any Medications and the dosages you are currently prescribed:
  • Square One DE Inc. CANNOT accept applicants on METHADONE or SUBOXONE maintenance programs.
  • Have you ever lived in a Recovery House before?*
  • *

  • Application Instructions

  • BY SIGNING THIS APPLICATION,
    you have honestly answered the above questions to the best of your knowledge. You understand the stipulations, guidelines, and provisions as stated in the Operational Rules and Procedures and agree to abide by them. You also agree to submit to a necessary probationary period. In the event that you are approved for entry into a Square One house and you violate your terms of probation, you herein agree to leave Square One properties without drama or resistance.
    I have read all the material on this application form including the Operational Rules and Procedures setforth. I have also answered each question honestly and want to achieve recovery from alcoholism and/or drug addiction without relapse.

  • Signature
  • Date/Time
     - -
    2 digit month, 2 digit day, 4 digit year :
  • Should be Empty: