Resident Application | Crystal Clear Vision LLC

About You

Full name

Date of birth

Phone number

Email address

Current address

Emergency Contact

Name

Relationship to you

Phone number

Recovery Information

Primary substance(s) of use (if it applies)

Date of last use

How long have you been in recovery?

Are you currently participating in recovery services?

Treatment provider (if it applies)

Case manager or peer support specialist

Their phone number

Health Information

Do you have any medical conditions we should know about?

Are you currently taking prescribed medications?

Any dietary restrictions or allergies?

Work & Income

Monthly income

Source of income (check all that apply)

If employed, who is your employer?

If unemployed, are you actively looking for work?

Living On Your Own

Can you prepare your own meals?

Can you clean your personal living space?

Can you manage your personal hygiene independently?

Can you manage your own finances?

Living With Others

Have you ever lived with roommates?

How do you usually work out a disagreement?

Your Goals

What are your goals for the next six months?

What strengths will help you reach them?

What support do you hope to get while living here?

References

Reference 1 — name

Reference 1 — relationship

Reference 1 — phone

Reference 2 — name

Reference 2 — relationship

Reference 2 — phone

Program Agreement

Check every box to show you agree.

I understand this is a drug- and alcohol-free residence.I agree to comply with all house rules.I understand random drug and/or alcohol screenings may be required.I agree to respect staff, residents, visitors, and neighbors.I understand that violence, threats, theft, or illegal activity may result in immediate discharge.I agree to participate in required meetings and recovery activities.I agree to maintain cleanliness in my room and shared spaces.

Sign & Send

By typing your name you certify the information here is true and complete to the best of your knowledge.

Type your full name as your signature

If you need any additional special assistance you can call us at 252-701-6683.