Program Application

Welcome to our online application. This application contains 12 sections.

Contact Information

If you are filling this out for yourself, enter your information here and in the RESIDENT DEMOGRAPHIC section. If you are completing this for a loved one, enter your information here and their information in the RESIDENT DEMOGRAPHIC section.

Full Name *

Email *

Phone *

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Resident Demographics

Resident Name *

Gender *

Resident DOB *

Resident Email *

Resident Cell *

Emergency Contact

If you do not have an emergency contact, please write DECLINE

EMC Name *

Relationship to Resident *

EMC Email Address *

EMC Phone Number *

Treatment History

Are you discharging from a Treatment or Detox Center? *

Yes

Please provide the treatment center's name, the dates you were there *

Medication History

Prescribed Medications: to select multiple medications, you will need to select the dropdown multiple times

Prescribed Medications *

Do you have a history of abusing any of these medications? *

Yes

One or more of the medications you select, will require a lock box, while living in the community. Are you willing to purchase a lock box prior to your admissions and use the lock box while living in the community? *

Sober Living History

Have you Lived in Sober Living Before? *

Yes

Did you leave sober living in the *

Have you been a resident of Eudaimonia Recovery Homes before? *

Yes

Were you a resident with Eudaimonia in *

Please be detailed in your response, in regards to why you left sober living. This response will be used to determine eligibility of residency.

Reason for leaving sober living *

Vehicle Information

Are you bringing a vehicle? *

Yes

Make and Model of the Vehicle *

Legal History

Have you had any of the following pending or criminal charges? Select all that apply *

Can you please provide some additional information, regarding the charges. Please be detailed around what happened and the state of mind you were in. We will use this information to determine eligibility for residency. *

Are you currently on probation? *

Yes

Are site visits required for probation? *

Yes

Are you currently or will you be on Parole? *

Yes

Are site visits required? *

Yes

Employment

Are you currently employed? *

Yes

Employer Name *

Job Title *

Length of Employment *

Work Schedule *

Is the work schedule overnights? *

Yes

Who will be paying for the sober living fee *

Monthly, Biweekly and Weekly payments, are due at the time of admissions. If you can not make the payment at the time of admission, select Other payment frequency option to speak with an admissions coordinator on a payment plan option. Biweekly, weekly and other payment options, are assigned a $25.00 fee associated to each invoice.

How will you be paying? *

Family Member or Friend Name *

Family Member or Friend Phone Number *

Family Member or Friend Email *

Program Information

Program Requirements

Residents are required to fulfill the following major requirements:

Attend at a minimum of 3 12 step recovery meetings per week.
Be actively working with a sponsor. If you do not have a sponsor, acquire one within 30 days of admission.
Either be employed full time, volunteering full time or enrolled in school on a full time basis.
Participate in weekly drug testing.
Participate in weekly chores.
Adhere to all program rules.

Are you able and willing to attend 3 12 step recovery meetings per week? *

Are you able and willing to work with a sponsor in a 12 step program of recovery? *

Are you able and willing to be employed full time, volunteer full time or enroll in school on a full time basis? *

Will you actively participate in weekly drug testing? *

Will you actively participate in weekly chores? *

Are you willing to adhere to all program rules? *

Admission Information

Site *

Are you Interested in a pet friendly unit? *

1. What Pets Are Allowed?

Dogs – small breeds only
Cats – indoor only

At this time, we do not allow other types of animals (reptiles, birds, rodents, etc.) as pets.

2. Weight Limit

Dogs must weigh 35 pounds or less at full-grown adult weight.
Puppies may be evaluated based on their expected adult size from a veterinarian.

If your dog is expected to grow over 35 pounds, it will not be approved. Only 1 pet per resident is allowed and there is a one-time $200.00 fee.

What type of pet? *

Please select the breed of dog *

Move In Date *

Completed by First and Last Name *

Signature *

Clear