OxfordHouseUtah.com
Donate Now

Online Application

Click Here for a printable application

Application For Membership In Oxford House
To be accepted in an Oxford House and applicant must complete this application and be interviewed by the residents of the particular Oxford House to which the applicant is applying. The residents of the house then vote on acceptance. An 80% affirmative vote is needed to be accepted. Carefully read the application and honestly answer the questions. Living in and Oxford House is special and if you understand its value it can help you achieve comfortable sobriety without relapse.
1. Name (First, Middle, Last)
3. Date of Birth
Present Address/if facility please provide - Name, Address, Contact Person, Phone Number

4. Phone Where You Can Be Reached
  Mobile
City
State
Zip

  Work
5. Are you an Alcoholic?
Yes No
6. Date of Your Last Drink?
9. List drugs you used addictively
characters left
7. Are you addicted to drugs?
Yes No
8. Date of last drug use?
10. When did you attend your first AA or NA meeting?
Have not attended one
11. How many AA/NA meetings do you attend each week?
12. Do you want to stop drinking alcohol and using addictive drugs?
Yes No
13. Are you employed?
Yes No If "Yes" who is your employer.
14. Are you getting welfare or other non-job related income?
Yes No If "Yes" what.
15. If you do not have a job will you get one?
Yes No If "Yes" what job plans do you have.
16. What is your monthly income right now?
17. What do you expect your monthly income to be next month?
18. Marital Status [Check One]
Married Never Married Separated Divorce
19. Do you have a medical doctor?
Yes No If "Yes" list the doctor's name and phone number.
20. Have you ever been to a treatment facility for alcoholism and/or drug addiction?
Yes No If "Yes" list the treatment provider, phone number and primary counselor, if any.
21. Do you take prescription drugs?
Yes No If "Yes" list drugs and reason the drug has been prescribed.
22. Date of move in? Immediately Other If "Other" list the date you would want to move in, if accepted, and why the date is in the future rather than immediately.
23. Contact information for your Probation/Parole Officer/Tracker/Therapist Name Phone#
24 A. How did you hear about our Home?


characters left
24 B. What did you hear?


characters left
25. Emergency Telephone Numbers.      [List family doctor, if you have one, + two family members or friends]
Name

1.
2.
3.
Address



Relationship



Telephone





26. I realize that the Oxford House to which I am applying for residency has been established in compliance with the conditions of § 2036 of the Federal Anti-Drug Abuse Act of 1988, P.L. 100-690, as amended, which provides that federal money loaned to start the house requires the house residents to (A) prohibit all residents from using any alcohol or illegal drugs, (B) expel any resident who violates such prohibition, (C) equally share household expenses including the monthly lease payment, among all residents, and (D) utilize democratic decision making within the group including inclusion in and expulsion from the group. In accepting these terms, the applicant excludes himself or herself from the normal due process afforded by local landlord-tenant laws.

Typing your name and date is used as a digital signature.

SIGNATURE: (Type name)
DATE:



27. Use this space for additional relevant information:
characters left
28. I have read all of the material on this application form including the limitations set forth in item 26. I have also answered each question honestly and want to achieve comfortable recovery from alcoholism and/or drug addiction without relapse.

Typing your name and date is used as a digital signature.

SIGNATURE: (Type name)
DATE:




©Copyright 2014