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Application for Consideration of Acceptance

Are you currently homeless?
Yes
No

Previous or Permanent Address

Date of Birth
Are you currently on Parole/Probation?
Yes
No
Are you currently incarcerated?
Yes
No
Are you in or applying for:
Do you have any active/pending cases or current charges?
Yes
No
Do you have any active warrants?
Yes
No
Have you been charged with a sex crime?
Yes
No
Are you, or have you ever been, registered as a sex offender?
Yes
No
Have you ever been charged with a violent crime?
Yes
No

By violent crime we mean that the alleged victim was harmed by violence or threatened with violence. Examples may include, but are not limited to: arson, rape, kidnapping, sexual assault, domestic violence, robbery, assault, battery, murder, and non-negligent manslaughter.

Do you have a substance use disorder?
Yes
No
Date of last use?
Drugs used?
Do you want to stop using drugs and/or alcohol?
Yes
No
Do you have a mental health diagnosis?
Yes
No
Do you take any prescription drugs?
Yes
No
Have you ever been admitted to a hospital, rehab, or other facility for substance abuse treatment?
Yes
No
Have you ever lived in a recovery house before?
Yes
No
Relationship Status
Single
Divorced
Married
Separated
Widowed
Spiritual Background?
Yes
No
Do you attend church?
Yes
No

Education

Diploma or GED
Yes
No

Do you understand that there is a fee to participate in the B.O.S.S. Life Sober Living Community which you will be responsible for monthly?

Yes
No

Note: Any resources and funding may be available and will be discussed further upon acceptance.

Do you primarily support yourself on income received from a source other than an employer?
Yes
No
If accepted, anticipated date to begin residing at B.O.S.S. Life, Inc.
Date Signed

By signing this application, you are agreeing to release personal Information to BOSS Life, Inc. in order to speak with probation and parole, court officers, and any person identified in your application so that we may

process your application for consideration. Furthermore, by signing, you agree to abide by all rules of the program and all of your answers herein are truthful, and that you may be removed from the program if any

false information was provided on this application.

Emergency Contact Sheet

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