Legal Name
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First Name
Last Name
Mailing Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email Address
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Phone Number
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Fax Number
Date of Birth
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Social Security Number
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Marital History
Children
Current Employer & Position
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Employment History
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Have you ever been charged with or pled guilty to a felony or misdemeanor?
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If you checked yes for the previous question, please list ALL charges.
Referred By:
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Next of Kin (include name, relationship, address and phone number) .
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Age and substance first used abused?
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Age you first became aware that you were abusing or addicted to these substances.
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Why do you use/abuse drugs or alcohol?
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Do you consider yourself an addict?
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What has your drug/alcohol use cost you personally?
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What makes you believe you are ready to address your drug /alcohol use?
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What is the cost of failure?
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What are your triggers?
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If accepted, how might you try to sabotage your experience with us and your recovery?
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What would be the warning signs to your mentor and housemates that you were entering the emotional state of relapse?
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What are you willing to do to create a life in recovery (be specific)?
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When and what did you last use?
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Longest period of sobriety in the past?
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Number of times sobriety attempted:
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Why did you relapse?
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What was your response to that relapse?
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Do you currently have a sponsor?
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If you answered yes to the previous question, please provide name and contact information:
If you answered no, have you ever had a sponsor in the past?
Have you ever worked a 12 step program?
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Have you ever participated in any inpatient treatment?
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If you answered yes to the previous question, please provide name, location, and length of stay.
List all drugs used/abused in the past, including tobacco products and approximate date of last use:
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Describe any sober living programs previously involved in, length of stay and reason for leaving.
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What do you believe the role of your mentor would be in helping you live that life in recovery?
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Have you ever been emotionally or sexually abused?
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Have you ever been physically abused?
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If you answered yes to the 2 previous questions, by whom?
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Location of abuser:
Approximate date of last event:
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Were charges filed?
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Last contact with the abuser:
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If accepted, the applicant agrees that the location of the mentoring house not be divulged to the abuser, or others known by the abuser.
Diagnosed medical conditions, treating physician and related prescriptions:
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Physical limitations, if any:
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Describe how you would like your life to be a year from now.
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What are your three best attributes?
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What is one thing, other than addiction, that you would like to change in your life?
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(Must be possible, even if you don’t understand how to do it)
What prevents you from making that change?
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If God were going to describe you to His angels, what words would He use?
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Other than drugs or alcohol, what is the main thing that holds you back from the life you want?
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1. No use of drugs or alcohol. Residents agree to random drug and alcohol testing. The Pellow House is a tobacco-free facility. No tobacco products or vaping allowed on the premises. 2. No pornography or gambling. 3. Romantic, flirtatious, or sexual non-marital relationships are not allowed while at the Pellow House. 4. No physical or, verbal abuse or threat of violence or intimidation. 5. Resident is required to check in with mentor between 12:00 noon and 3:00 p.m. every day. 6. Curfew is 8:00 PM for any new resident. For all others, curfew is 10:00 PM unless extended by mentor. 7. All residents are required to have employment. Two meetings a day are required until employment is obtained. Meetings are available in the metro area from 5:00 a.m. to 8:00 p.m. 8. Spirituality is a must in recovery. Attending weekly and being active in a Christian church of your choice is required. 9. All residents agree to a minimum of 4 hours per month of community service 10. Resident will attend the Pellow House Schedule, No Excuses AA, Celebrate Recovery, PO men’s mentoring, or other meetings as directed by mentor. 11. Residents agree that no over the counter drugs will be utilized without the approval of the mentor. 12. No guests are allowed at the Pellow House unless approved by the mentor. Approved guest are restricted to the common areas of the house and are the responsibility of the occupant. 13. Resident is financially responsible for any damage he or their guest have caused to the facility or its contents. 14. Resident will respect the privacy and property of other residents and neighbors. 15. No parking in front of neighbors homes. 16. Residents are expected to practice daily hygiene and good grooming habits. Sideburns, mustaches and beards should be neatly trimmed. Piercings are not permitted. 17. Language should be polite and lacking in vulgarity. 18. Housekeeping Responsibilities: Housekeeping/Yard chores will be assigned weekly. Personal area: Bed made, clothes properly put away, and bathroom left clean at all times. Common areas: Are to be kept clean and neat at all times, with any items, including those used for eating, cooking, crafts, housecleaning, etc, being cleaned and put away immediately following use. 19. Overnight privileges may be granted through Joe Pellow only if resident is actively working, has obtained a sponsor, and completed Step 1 of either the AA or Celebrate Recovery programs. I have read and agreed to follow all of the Pellow House rules.
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