Phase Two Application Name * First Name Last Name Phone * (###) ### #### Email * Date of Birth * Current Address How many days clean do you have? * Primary substance of use Do you currently have a sponsor? * Yes No Have you completed the first three steps? * Yes No Most recent treatment program attended Program Type Residential IOP PHP Sober Living Length of stay Contact Person Their phone/email Current Employer * Position * How long employed there * Monthly Income * Do you have a personal vehicle? * Yes No If no, what is your reliable transportation plan? How many recovery meetings do you attend weekly? * Preferred Recovery Fellowship (AA/NA/CR/other) Do you agree to attend at least 3 outside recovery meetings per week? * Yes No Do you agree to attend the mandatory weekly house meeting? * Yes No Any pending legal issues? * Yes No If yes, please explain Are you on probation or parole? * *this does NOT disqualify you* Yes No If yes, list officer name and number Why do you want to move into Phase Two? * What are your goals for the next 6-12 months? * Add anything here that you wish to be considered in your application process! Thank you!
