Application for Membership

The Reuben Center believes community is a key component to keep recovery alive. Therefore, to be accepted into our home an applicant must complete both pages of this application then interview with the house members during a weekly house meeting. At the meeting each member anonymously votes. If an 80% majority vote is reached the applicant will then be accepted. Carefully read and answer all questions honestly.

First Name

Last Name

Date of Birth

Current Address

Phone Number

Are you an Alcoholic?
 Yes No

Are you an Addict?
 Yes No

Drug of choice?

Do you want to quit?

Are you employed?
 Yes No

If you are unemployed do you plan on working?
 Yes No

Do you receive welfare or other non-working income?
 Yes No

Current monthly income?

Have you been to a treatment facility?
 Yes No

If “yes” what was the most recent facility and your councilor’s
name and phone number?

Date you would like to move in?
 Other

If you lived in a sober living house before, what was your reason for leaving?
 Immediately
 Voluntarily
 Other

Do you attend AA/NA meetings?
 Yes No

How many per week?

Do you have a sponsor?
 Yes No

Date of last use?

Marital status?
 Married Single Separated Divorced

Number of children?

Do you have a doctor?
 Yes No

If “yes” what is your doctors’ name and number.

Do you take any prescription pills?
 Yes No

If “yes” please list name and reason for prescription.

Do you take any prescription pills?
 Yes No

Have you lived in a sober living house before?
 Yes No

If “Yes” please provide the location and Phone Number.

Do you owe money to any other sober living houses at this time?
 Yes No

If yes are you making payments to them currently?
 Yes No




Emergency Telephone Numbers. List family doctor, if you have one, and two family members or friends
















Do you have any past or pending sex abuse charges or have to register as a sex offender?  Yes No

I have read all of the material on this application form. I have also answered each question honestly and want to achieve comfortable recovery from alcoholism and/or drug addiction without relapse.

 ACCEPTED NOTACCEPTED

MOVE IN DATE

HOUSE KEYS RETURNED
 Yes No

MOVE OUT DATE

DEBT TO HOUSE
 Yes No

AMOUNT