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DalMont Phoenix Foundation for Sober Living

DalMont Phoenix Foundation House Lodger Application

Personal Information

First name*

Last name*

Birthday*

Month

Day

Year

Male or Female*

Male

Female

Phone*

Email*

House applying for?*

CL Huson House (Mens) Plymouth Wi.

What is your substance of Choice*

What is your sobriety date?*

Month

Day

Year

What prescription medications and nonprescription medications are you currently taking? How much and how often for each?*

What does YOUR recovery mean to you?*

Are you currently employed?*

If not, are you willing to find work within 30 days?

Company name if working:

Supervisor (for emergencies only)

Contact number

Position

Start Date

Monthly Salary

$

Emergency Contacts

Name*

Phone*

Name*

Phone*

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