Achieve Recovery Homes Residential Application Apply online below. Personal InformationFull Name(Required) First Middle Last Referring case manager / counselorCurrent Address Street Address City State / Province / Region ZIP / Postal Code Cell Phone Number(Required)Home Phone NumberEmail(Required) Date of Birth Driver’s License NumberSocial Security NumberMarital StatusSingleMarriedDivorcedSeparatedEngagedWidowedHave you ever been arrested for any Sexual Offense? Yes No Were you convicted of any Sexual Offense? Yes No Are you a registered Sex Offender? Yes No Have you ever been arrested for any reason? Yes No If so, please briefly explainDo you have any outstanding warrants? Yes No Do you have any pending court cases? Yes No Are you out on bail? Yes No Are you on probation? Yes No Are you on parole? Yes No Name of parole / probation officerHave you been tested for AIDS/HIV? Yes No Results Positive Negative Date of last test Have you been tested for Hepatitis C? Yes No Results Positive Negative Date of last test Are you currently being treated for any illness? Yes No If yes, please briefly explainAre you currently taking any medications prescribed by an MD? Yes No **This includes any medication assisted treatment**Name, strength, and dosage of medications:NameStrength (mg)Dosage Add RemoveAre you currently using medical marijuana? Yes No Are you currently using steroids? Yes No Are you diabetic? Yes No What is your drug of choice?When is the last time you used alcohol or any other drugs?Is this your first sober living experience? Yes No If no, please explain why you left, and when:Are you currently employed? Yes No If yes, where at?Approximately how much do you make per month?Do you have any dependents? Yes No If yes, how many?Do you pay child support? Yes No If yes, how much per month?Who will be paying your rent? Myself Family Member Other If other than yourself- Enter Name First Last PhoneIn case of emergency, contact:Full Name First Last RelationshipAddress Street Address City State / Province / Region ZIP / Postal Code Phone NumberGuest SignatureDate Manager SignatureDate Achieve Recovery Homes grew out of the need to help more people. These people needed to have a safe and supportive place to live while they work on sobriety and ACHIEVING a life free of drugs or alcohol. Looking for Sober Living? Begin your Journey Contact Us Today Ben Reiswig - CEO*protected email* PHONE: 701-318-3509TEXT LINE: 701-318-3509 *protected email* *protected email* Location: OFFICE: 701-318-3509 PO Box 7Fargo ND 58107
