Application Form

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INTO ACTION - APPLICATION FORM

If you've not yet spoken to an Into Action representative, then we recommend doing that first to make sure there are vacancies available.

* Indicates required field

Name *

First

Last

Are you currently in inpatient treatment, incarcerated, etc? *

Yes No

If so, then when is your expected discharge date? *

Call Back Number *

Type of Phone *

Alternate Call Back Number *

Type of Phone *

Contact Email - This will never be used for anything but to contact your about your application. *

Are you able to access your email? (For example, some treatment centers do not allow email access) *

Yes No

Who's email is this? *

Mine Case Manager Parents / Friend

Age? Must be 18 or older to apply. *

Do you have any violent, sexual, or arson based FELONY convictions? *

Yes No

If "Yes", what are they? Any other felonies and/or misdemeanors do not matter. *

Are you on any medications regardless of whether or not they are over-the-counter or prescribed? *

Yes No

If so, what medications and why do you take them? And if you are taking them in treatment, jail, etc. will you still be taking them once you are discharged? *

Why are you looking for sober living (In other words, "What's your current situation")? *

Do you currently have a job? If so, tell us about it. If not, are you willing to spend a minimum of 40 hours per week putting in a bare minimum of 10 job applications per day? *

The costs to live at Into Action is $105 per week + a one time Move-In Fee of $145 (of which $115 is refundable upon moving out). How are you planning on paying for this? *

Have you thoroughly reviewed our website to see if this is truly what you are looking for? *

Yes No

Do you already know which Into Action house you want to live in? *

Why do you think you are a good fit for an Into Action Sober Living house? *

Submit

﻿INTO ACTION - APPLICATION FORM﻿

INTO ACTION - APPLICATION FORM