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Full Name*

Desired Move in Date*

Sobriety Date*

Birth Date*

Current Address*

Living Arrangement*

Own Your Home

Rent

Staying with Friend/Family

Homeless

Phone Number*

Email Address*

Marital Status*

Married

Divorced

Widowed

Never Married

Emergency Contact*

Emergency Contact Relationship to You*

Are you Currently Employed?*

Yes

What is your monthly Income from Employment?*

Current Employer’s Name*

Current Employer’s Address*

Do you Have an Alternate Source of Income*

Yes

Alternate Monthly Income Amount*

Alternate Income Source*

Contact info for Other Income*

Are you on Probation, Parole, or Bond, or any other Legal Restrictions in the State of Michigan? *

Yes

If yes, please describe:*

Current Probation/Parole Officer Name*

Contact Phone and/or Email*

Are you currently taking any prescription medication?*

Yes

If yes, please list all medications with prescribed dosage.*

Are you an Alcoholic?*

Yes

Are you addicted to drugs?*

Yes

Have you been admitted to a treatment center in the past?*

Yes

If yes, where and when?*

Please list any drugs (legal or illegal) you have abused in the last 5 years:*

Please list any other addiction you have (shopping, stealing, gambling, sex, porn, etc.):*

Do you have an AA/NA Sponsor?*

Yes

Sponsor Name / Phone #*

Are you currently working on any other personal prgram of recovery?*

Yes

What are you doing to better yourself and stay sober?*

Please provide any further information we should know about you:*

I have answered the above questions and provided all the information to the best of my ability. I have read and I agree to abide by Blue Bear Houses' Code of Conduct. I understand that if I am in violation of any part of the Code of Conduct, I will be required to vacate the premises upon request from a representative of Blue Bear Houses.*

Yes

Applicant Signature*

Today's Date*

Or, fill out the Application Form below, and we will contact you ASAP.

*If you apply using this form, please be sure to first read and agree to:

Blue Bear Houses' Code of Conduct

APPLICATION FORM

Location

Address

Livingston County, MI

Hours

9 AM - 5 PM

Admin@BlueBearHouses.com

Contact

Get in touch

(socials coming soon)

Email

info@bluebearhouses.com