Recovery Base
Columbia, South Carolina
Sober Living Residence Application
Website: www.myrecoverybase.com
Email: info@myrecoverybase.com

Personal Information

Full Name: _____________________________________________
Date of Birth: ____________ Phone Number: ___________________
Email Address: __________________________________________
Social Security Number (last 4 digits): ________
Emergency Contact Name: _________________________________
Emergency Contact Phone: ________________________________
Relationship: ___________________________

Recovery InformationR

1. Are you currently sober? □ Yes □ No
2. Date of last use: __________________
3. Primary substance(s) used: _____________________________________
4. Are you currently enrolled in a treatment program? □ Yes □ No
   If yes, provide name and location: __________________________________
5. Have you lived in sober living before? □ Yes □ No
   If yes, where and when? ___________________________________________
6. Do you have a sponsor? □ Yes □ No
   Sponsor Name & Phone (if applicable): _______________________________

Medical & Legal History

1. Do you take prescribed medications? □ Yes □ No
   List medications: _______________________________________________
2. Do you have any medical or psychiatric diagnoses? □ Yes □ No
   If yes, explain briefly: ___________________________________________
3. Do you have any legal obligations (probation, parole, court dates)? □ Yes □ No
   If yes, provide details: ___________________________________________

Employment and Financial Information

1. Are you currently employed? □ Yes □ No
   Employer: ______________________ Position: ______________________
2. Monthly income (if any): $_____________
3. Are you able to pay weekly program fees of $_______? □ Yes □ No
   If no, explain: _________________________________________________
4. Are you receiving any benefits (SSI, SSDI, etc.)? □ Yes □ No
   If yes, list: ____________________________________________

Recovery Base Requirements for Entry

By initialing each line, you agree to the following:

_____ I agree to remain 100% substance-free during my residency.
_____ I agree to submit to random drug and alcohol testing.
_____ I agree to pay my program fees on time and participate in house meetings.
_____ I agree to follow the house rules, curfew, and chore schedule.
_____ I understand that relapse may result in immediate discharge.
_____ I agree to actively work a recovery program (AA/NA, therapy, etc.).
_____ I understand that violence, threats, or disruptive behavior are grounds for discharge.
_____ I will respect my housemates and help maintain a safe and clean environment.
_____ I understand Recovery Base is not liable for lost or stolen personal property.
_____ I understand this is a communal living environment, and cooperation is expected.

Referral Information (To be completed by sponsor, caseworker, or treatment provider)

Name of Referring Person: ____________________________________
Organization/Agency: ________________________________________
Phone Number: ___________________ Email: _______________________
Relationship to Applicant: _________________________________

Brief Statement (why you recommend this applicant for sober living):

Signature of Referring Person: __________________________ Date: ____________

Statement of Intent

In your own words, please describe why you want to live at Recovery Base and what your goals are in recovery (minimum 3 sentences):

Signature & Consent

By signing below, I affirm that all information provided is truthful and complete. I understand that submitting this application does not guarantee acceptance. I authorize Recovery Base to contact references, verify information, and communicate with any probation/parole officers or treatment providers as needed.

Applicant Signature: ____________________________
Date: __________________

Recovery Base Representative (Optional): ____________________________
Date: __________________