To complete the application process, please fill in the information below and submit the application via mail, fax, email or telephone, using the information above.  Thank You!

PAROLEES:  Please fill in the information below and mail along with your check or money order for $130.00 (Non-refundable) to the address above. Once we receive word from the Facility Release Coordinator to hold a bed, we  will start applying your application fee toward your fees.  Any remaining balance will be applied towards your $130.00 weekly fee upon your arrival.  For bed availability please contact: (781) 229-0877.  Final approval is contingent on the parole officer’s review of your record, along with our sober home’s policies. Your acceptance into the Twelve-Step Education Program requires that you make a six-month commitment to our program during which, you will abide by all house rules.

Name                                                                                               Date of Birth                                                                                 

SSN#

Address

City                                                                                                                             State                          Zip                                           

Telephone #                                                                                   Fax#

PREFERRED TWELVE STEP LOCATIONS:    1:                                                                         2:                                  

List any Prescription Medications:

What 12step fellowships, if any, do you attend? (AA, NA, CA, etc)

Have you ever lived in a Twelve Step Education Program Sober Home?                                            yes    p            no     p

If so, which location? _________________________________

Are you involved in any legal action:                                                                                                                   yes   p             no     p

If yes, please explain:              

Are you a veteran?                                                                                                              yes   p               no   p     

Are you required to register as a sex offender:                                                                                      yes   p               no   p     

Have you been convicted of arson:                                                                                                                      yes   p               no   p

If leaving a prison system, will you be on probation or parole.                                                         probation      p        parole   p

Source of Income:                                                                                                                     Salary (weekly/monthly):                    

Signature:                                                                                                                                          Date: