THE UNIVERSITY OF HOUSTON
UNIVERSITY HEALTH SERVICES
COUGARS IN RECOVERY (CIR)
PROGRAM APPLICATION
Cougars in Recovery (CIR) welcomes applicants who are in recovery from alcohol and/or other
addictions.
CIR applicants must meet the following requirements:
1. Applicants must gain admission to the University of Houston through the normal
admission process.
2. Applicants must have a completed housing application on file. Go to
www.uh.edu/housing and click on “Apply” to locate the application.
3. Applicants must document consistent participation in and commitment to a 12-Step or
other structured program of recovery.
4. Applicants must document a minimum of 30 days of continuous abstinence and/or
management of addiction.
Please type or print clearly in black ink.
Date
My UH ID Number________________
Last Name
First Name
Middle Name
Date of Birth
Sobriety Birthday (commitment to recovery) _______________________________________
Sex: Male Female
Permanent Address
Permanent Phone (
)
Local Address
Local Phone (
)
Email Address
1
ACT/SAT Scores
Are you currently enrolled or have you previously been enrolled at the University of
Houston? Yes No
If yes: Hours completed
Cumulative GPA
Last semester attended
When do you plan to return to UH? _______________________________________________
Are you currently living on campus at UH? If so, where?______________________________
Have you ever lived on campus at UH? If so, when and where?_________________________
Other Colleges and Universities Attended:
1. ____________________________ Hours
GPA
Last Attended
2. ____________________________ Hours
GPA
Last Attended
List any activities, interests, honors, and/or special talents or skills that might be of interest
to the admissions and scholarship committees:
______
Briefly, what do you want to do with your college degree?
List your primary drugs of choice & addictive behaviors:
1.
2.
3.
Are you currently attending any recovery related meetings? Yes
No
If yes, what meetings?
1. _____________________________________________________________________________
2. _____________________________________________________________________________
What recovery programs are you currently working?
1. _____________________________________________________________________________
2
2. _____________________________________________________________________________
Please list any treatment programs, halfway houses, prisons, and/or mental hospitals that
you have attended:
1. Facility
Dates
Diagnosis or reason for stay
2. Facility
Dates
Diagnosis or reason for stay
Attach to this application a biographical narrative that includes the following information:
 Your addiction and recovery experience. (Include when you started using, main
reasons you used, number of times relapsed, etc.)
 What recovery means to you and how it plays a role in all areas of your life.
 How you are connected to your current recovery community. (Home group, treatment
center alumni, church fellowship, etc.)
 How you see academics enhancing your recovery.
 Why you feel as though you would be an asset to the CIR program.
Please limit the length of this narrative to two pages, typed and double-spaced.
Return application to:
Signature
Barbara Dwyer, Program Coordinator
Cougars in Recovery
4385 Wheeler Street, S-102D
Houston, TX 77004
bedwyer@central.uh.edu
Date
3