Application | Hero HouseWV

HERO HOUSE/FULTON HOUSE

Faith-Based Sober Living Homes

Residency Application/Evaluation

Hero House Inc. is a faith-based recovery program that integrates spiritual principles with evidence-based practices to support individuals in achieving and maintaining sobriety. Our approach emphasizes the importance of faith, prayer, and moral guidance alongside practical recovery tools. We believe that a strong spiritual foundation provides hope, purpose, and strength throughout the recovery journey.

Personal Information

First name

Last name

Birthday

Month

Day

Year

Social Security Number

Current Mailing Address

Current Physical Address

Phone

Emergency Contact Information

Contact Name

Contact Phone

Relationship to Contact

How long have you been in recovery?

Do you have a sponsor?

Yes

No

If yes, how often do you meet or speak with your sponsor?

Have you previously participated in a detox or residential recovery program?

Yes

No

If yes, please provide details:

What is your current employment status?

Full-time

Part-time

Unemployeed

Other

Please describe your employment history (most recent jobs, dates of employment, and positions held):

Do you have any specific career goals or plans for employment while in residency?

What are your personal recovery goals during your time at Hero House Inc.?

Please list the members of your support system (e.g., family, friends, sponsor, recovery peers, church, etc.):

Do you participate in any faith-based or spiritual activities?

Yes

No

If yes, please describe:

Additional Personal Information

Marital Status

Single

Married

Divorced

Widowed

Date of Last Use (Drugs or Alcohol):

Month

Day

Year

Primary Drug of Choice:

How long have you been using?:

Have you ever tried to quit before?

Yes

No

If yes, please explain:

Are you currently under a doctor’s care?:

Yes

No

If yes, list reason and doctor’s name:

List ALL current symptoms:

List ALL current medications (include dosage and frequency):

List all known drug and/or food allergies:

Behavioral and Legal History

Have you ever displayed violent behavior?:

Yes

No

If yes, please explain:

Are you currently on bond, probation, or parole?:

Yes

No

Nature of conviction(s):

Are you awaiting a court hearing?:

Yes

No

Location of Hearing:

Attorney’s Name (if applicable):

Are you a registered sex offender?:

Yes

No

ACKNOWLEDGEMENTS (Initial each)

I understand that completing this application does NOT guarantee acceptance into Hero House Inc.

I affirm that Hero House Inc. is a faith-based program and I agree to adhere to faithbased principles during my stay

I understand that I am expected to obey staff at all times. Failure to do so may result in disciplinary action, including dismissal.

Referral Source (if applicable):

Signatures

Applicant Signature:

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Applicant Signature Date

Month

Day

Year