APPLICATION | ClearwaterCreek2

Clearwater Creek Sober Living

Application For Services

Caldwell Idaho

208-800-3726

We understand that housing is a critical asset in supporting you on your journey towards recovery. We are dedicated to providing a supportive recovery residence, focused on establishing a strong sense of community, structure, accountability and stability that is essential for achieving your recovery goals. We provide resource connections to enhance individual support networks, employment opportunities, self-reliance, and self-efficacy. Clearwater Creek is designed to be a stepping stone on your path to creating a life that you are proud of, where you feel empowered, valued and capable to facing life’s challenges without resorting back to addictive behaviors.

Upon receiving your application, Clearwater Creek will contact the applicant via phone to schedule a time for a more in-depth phone interview with the applicant and with either the Live-In Resident Manager and/or the Housing Operations Manager.

First name*

Last name*

Birthday

Month

Day

Year

Phone

Address

Where are you currently living?*

Homeless

Treatment Facility

Personal/Family Residence

Staying with others to avoid homelessness

Jail

Other

Have you contacted Magellan Health to assist with payment?*

Yes

Are you CURRENTLY under State or Federal supervision (Probation or Parole)?*

Yes

Probation or Parole officer's name

Are you willing to sign a release of authorization for Clearwater Creek Sober Living? (*if you are currently under supervision, this will need to be completed)

Yes

Are you currently on pre-trial release?*

Yes

Are you currently incarcerated?

Yes

If you answered "yes" to any of the above questions, please list all convictions and date(s)

Have you ever been convicted of the following?*

Sexual offense or crime

Arson

Violent offense or crime

Robbery

Manufacturing of an illegal substance

Transportation of an illegal substance

None of the above

Admission to a crime is not an automatic disqualification

If you checked any of the boxes above, please provide the offense and date(s) of the offense

Substance use history*

Treatment history*

Are you currently attending treatment*

Yes

Previous periods of Sobriety (length of previous sobriety, when, what helped, meetings) *

Current Recovery Program - What does your program of recovery look like today? *

Sober Living History (include name(s) and date(s)*

Have you been diagnosed with mental health disorders beyond alcoholism and/or addiction? *

Yes

If you answered yes to the above question, what is the diagnosis?

Are you taking any medication for mental health or substance abuse? *

Yes

If you answered yes to the above question, please list the medication(s) you are taking

Clearwater Creek does not manage, hold, distribute or advise on medication or medical concerns

What is your expected move in date? *

Are you currently employed? *

Yes

Recieving SSI/SSDI

Other

If you answered yes to the above question, please provide the location and duration of your employment

Do you have any health problems that would interferes with daily functioning? *

Yes

If you answered yes to the above question, please provide the health issue

Do you have a driver's license?*

Yes

Do you have a legal vehicle? *

Yes

If you answered yes to the above question, please provide license plate and registration information

Are you willing to submit to a background check? (*every applicant is required to submit to a background check)*

Yes

Signature*

Signature field is empty.

Date picker*

Clearwater Creek Sober Living

Application For Services

Caldwell Idaho

208-800-3726

clearwatercreeksoberliving@gmail.com

First name*

Last name*

Birthday

Month

Day

Year

Phone

Address

Where are you currently living?*

Homeless

Treatment Facility

Personal/Family Residence

Staying with others to avoid homelessness

Jail

Other

Have you contacted Magellan Health to assist with payment?*

Yes

Are you CURRENTLY under State or Federal supervision (Probation or Parole)?*

Yes

Probation or Parole officer's name

Are you willing to sign a release of authorization for Clearwater Creek Sober Living? (*if you are currently under supervision, this will need to be completed)

Yes

Are you currently on pre-trial release?*

Yes

Are you currently incarcerated?

Yes

If you answered "yes" to any of the above questions, please list all convictions and date(s)

Have you ever been convicted of the following?*

Sexual offense or crime

Arson

Violent offense or crime

Robbery

Manufacturing of an illegal substance

Transportation of an illegal substance

None of the above

Admission to a crime is not an automatic disqualification

If you checked any of the boxes above, please provide the offense and date(s) of the offense

Substance use history*

Treatment history*

Are you currently attending treatment*

Yes

Previous periods of Sobriety (length of previous sobriety, when, what helped, meetings) *

Current Recovery Program - What does your program of recovery look like today? *

Sober Living History (include name(s) and date(s)*

Have you been diagnosed with mental health disorders beyond alcoholism and/or addiction? *

Yes

If you answered yes to the above question, what is the diagnosis?

Are you taking any medication for mental health or substance abuse? *

Yes

If you answered yes to the above question, please list the medication(s) you are taking

Clearwater Creek does not manage, hold, distribute or advise on medication or medical concerns

What is your expected move in date? *

Are you currently employed? *

Yes

Recieving SSI/SSDI

Other

If you answered yes to the above question, please provide the location and duration of your employment

Do you have any health problems that would interferes with daily functioning? *

Yes

If you answered yes to the above question, please provide the health issue

Do you have a driver's license?*

Yes

Do you have a legal vehicle? *

Yes

If you answered yes to the above question, please provide license plate and registration information

Are you willing to submit to a background check? (*every applicant is required to submit to a background check)*

Yes

Signature*

Signature field is empty.

Date picker*