Online Application for Sober Living Program

Please be as complete as possible.

First Name

Middle Name

Last Name

Gender

Male Female

Birth Date:

Social Security Number:

Driver License Number:

Driver License State:

TDCJ ID Number (if applicable):

Phone Number

Email Address

Current Address

City

State

Zip Code

Are you an alcoholic?

Yes No

Last drink on:

Are you a drug addict?

Yes No

Last drug use on:

List of drugs used:

Last recovery meeting attended on:

Are you employed?

Yes No

Employer Name

Employer Phone Number

Do you receive welfare, SSI, disability or any other income?

Yes No

If other income, please explain:

What is your monthly income?

Marital Status?

Medical Doctor: Name

Medical Doctor: Phone Number

Do you take prescription drugs?

Yes No

List of prescription drugs used:

Have you been in a treatment facility for drugs or alcohol?

Yes No

Treatment Facility: Name

Treatment Facility: Phone Number

Treatment Facility: Primary Counselor Name

Rehab Facility: Discharge Date

Mental Health Info:

Are you on Probation or Parole?

Yes No

Officer Name

Officer Phone Number

Do you have a pending court case?

Yes No

Do you have any active warrants?

Yes No

Have you been convicted of a felony?

Yes No

Felony conviction info (if yes):

Are you a registered sex offender?

Yes No

Emergency Contact Name:

Emergency Contact Phone Number

Emergency Contact Relation:

Reference 1 Name:

Reference 1 Phone Number

Reference 2 Name:

Reference 2 Phone Number

Who referred you to Titus 2 Communities?

Do you have your own car?

Yes No

Vehicle License Plate Number

Vehicle License State

Vehicle Make

Vehicle Model

Vehicle Year

Desired Move-in Date:

Any additional relevant info:

I have read and agree to follow all rules of the program. See Rules.

I agree to follow all rules of the program. (Check box to indicate agreement)

I realize that Titus 2 Communities is a Christian Organization and:

it prohibits all residents from using any alcohol or illegal drugs;
it may expel any resident who violates such prohibition;
mentoring is a requirement;
failure to pay weekly membership fees is cause for removal from the program;
each applicant signs the list of rules and agrees to follow them;
not following ALL rules may be cause for immediate removal from the program and all housing.

By signing this application:

I authorize Titus 2 Communities to do a background check and process my application.
I understand that I am entering a program that includes housing. At any time that I may be discharged from the program I am also immediately discharged from the residence.
I verify that all information submitted is accurate and true and that falsification of information is cause for removal from the program.

Sign by entering your full name.

Electronic Signature