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Application for Membership in Oxford House
Have you applied here before?
If so, enter your email address to retrieve your most recent application.
Email Address
Email Address
required
Personal Info
Print Name (First, Middle, Last)
required
Pronouns
required
-- Select Pronouns --
He/Him
She/Her
They/Them
Other
Present Address
City
State
-- Select State --
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Date of Birth
Month
required
Day
required
Year
required
Phone Where You Can Be Reached
Home or Cell
required
History
Do you have an alcohol problem?
required
Yes
No
Date of Last Drink
required
Do you have a drug use problem?
required
Yes
No
Date of Last Drug Use
required
List all the drugs you misused:
required
How many recovery meetings do you attend per week?
required
Do you want to stop using/drinking?
required
Yes
No
Employment
Are you employed full-time?
required
Yes
No
Monthly income from employment
required
Are you receiving other income?
(retirement, disability, family, welfare)
required
Yes
No
Amount of other monthly income
Marital Status
Required
Single
Married
Separated
Divorced
Widowed
Medical Info
Treatment/Facility Name
Treatment Contact Name
Treatment Contact Phone
List all the medications you are currently prescribed:
required
Doctor Name
Medical Doctor Contact Number
Mental Health Professional Name
Mental Health Professional Contact Number
Name of Last Treatment Center/Detox:
Number of Times in Treatment/Detox:
required
Move-in Info
Can you move-in immediately?
required
Yes
No
If no, give the reason
-- Select Reason --
Finishing Treatment/Detox First
Getting Out of Jail/Prison
Job Related
Moving from Another City or State
Personal/Family Reasons
Waiting for Paycheck/Money
Other
Have you lived in an Oxford House before?
required
Yes
No
If yes, list the house name
If yes, what was the reason of your departure?
Voluntary
Relapse
Disruptive Behavior
Nonpayment of EES
If yes, did you leave owing money?
Yes
No
If "yes" how much?
Emergency Contacts
Contact 1 Name
required
Contact 1 Relationship
required
-- Select Relationship --
Aunt/Uncle
Boss/Employer
Boyfriend/Girlfriend
Cousin
Child
Doctor
Friend
Grandma/Grandpa
Myself
Parent
Probation/Parole Officer
Sibling
Sponsor or Recovery Support
Spouse/Partner
Therapist/Counselor
Other
Contact 1 Phone
required
Contact 2 Name
Contact 2 Relationship
-- Select Relationship --
Aunt/Uncle
Boss/Employer
Boyfriend/Girlfriend
Cousin
Child
Doctor
Friend
Grandma/Grandpa
Myself
Parent
Probation/Parole Officer
Sibling
Sponsor or Recovery Support
Spouse/Partner
Therapist/Counselor
Other
Contact 2 Phone
Contact 3 Name
Contact 3 Relationship
-- Select Relationship --
Aunt/Uncle
Boss/Employer
Boyfriend/Girlfriend
Cousin
Child
Doctor
Friend
Grandma/Grandpa
Myself
Parent
Probation/Parole Officer
Sibling
Sponsor or Recovery Support
Spouse/Partner
Therapist/Counselor
Other
Contact 3 Phone
Additional Information
Use this space for additional relevant information:
Signature
required
Please sign below:
Clear Signature
Where are you looking for a house?
State
required
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
GH
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MO
MS
MT
NC
NE
NJ
NM
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
VA
VT
WA
WI
WV
County
required
Gender
required
Male
Female
Only houses that allow children
# Houses that will receive application
I understand that the Oxford House to which I am applying is not run, managed, or supervised by Oxford House, Inc., and that Oxford House, Inc. does not provide any services or treatment to the Oxford House or its residents. As such I release Oxford House, Inc. for myself and for my heirs, executors, administrators, and assigns, from any and all suits, claims, demands and causes of action, known or unknown, of whatever kind, that may arise from my residency at the Oxford House to which I am applying.
Oxford House, Inc. does not provide direct, ongoing, or preventative services related to an individual's recovery, nor does it monitor any individual's continued adherence to sober living- these are all self-monitored journeys - whether they be successful or otherwise is outside the purview of Oxford House, Inc. as it does not monitor any individual's journey or provide any individual services at any time.
I realize the Oxford House to which I am applying for membership has been established in compliance with the conditions of §2036 of the Federal Anti-Drug Abuse Act of 1988, P.L. 100-690, as amended, which provides federal money loaned to start the house requires the house members to (A) prohibit all members from using any alcohol or illegal drugs, (B) expel any member who violates such prohibition, (C) equally share household expenses, including the monthly lease payment, among all members, and (D) utilize democratic decision making within the group including inclusion in and expulsion from the group. In accepting these terms, the applicant understands that §2036 conditions are different than the normal due process afforded by some local landlord-tenant laws.
I have read and understand the disclaimer above
required