To Prospective New House Guest,
If you’re reading this now, then that means you deserve congratulations! You’ve made it through the hard
part and are ready to begin living life again. Into Action, LLC would like to help you succeed. You may be
wondering what all is involved from now to the point that you move in to Action House. Well it’s pretty
simple.
And if you’re this far, then we assume you have already taken the time to fully review our website and
have decided you are ready to apply to become a House Guest.
Step 1:
- Download, fillout, and email the application back to info@intoactionllc.com
- Please write very neatly when filling out the application. And remember, if you are pre-approved for
entry, we will perform a background check prior to final approval. So please be as thorough and honest
as possible.
Step 2:
- If your application is accepted, then we will contact you to schedule a telephone interview.
But first, we wish to communicate to you that your information is safe!
Into Action Privacy Policy
We recognize that your privacy is extremely important. Into Action, LLC takes this very seriously and will
protect the information you provide. So, it is with our firm commitment to your anonymity, that we have
provided an Into Action Privacy Policy, which is included in this Agreement.
But in short, no personal information in your application will be distributed to any other person who is not
an Into Action Manager, or to any outside entities, beyond what you specifically consent to, or what we
are required to disclose by law.
Thank you for your time and interest. We hope to see you soon!
Sincerely,
Brian Sabolich
Into Action, llc Manager
Into Action, LLC Application for Entry
If there are any questions in the application portion which you are not able to answer because you do
not have the information, please sign your initials next to the item.
FINANCIAL
Income:
Take Home Pay
Day/Week/Month
Source(s) of income? _________________________________ Amount: ___________ Per:___________
Source(s) of income? _________________________________ Amount: ___________ Per:___________
Source(s) of income? _________________________________ Amount: ___________ Per:___________
Monthly Expenses
Into Action:
Food:
Fellowship:
Car Payment:
Car Insurance:
Car Maintenance:
Credit Cards:
Savings:
Total Income:
Total Expenses:
Total Remaining:
___________
$200_______
$30________
___________
___________
___________
___________
___________
___________ per month
___________ per month
___________ per month
OCCUPATION
_____________________________
Employer
_____________________________
Employer
Other Expenses
Into Action Entry Deposit:
*_____________
*Other options available to fulfill deposit requirements to qualify.
Legal Expenses Fill in details (Lawyer, Court, etc.):
______________
______________
______________
Other Expenses (minus 9th Step) ______________
______________
______________
______________
______________
______________________________
__________________
Type of Work:
Total Hours per week:
________________________________ __________________
Type of Work:
Total Hours per week:
Supervisor Name: _________________________________
Phone #: ____________________
Is it alright to:
Contact your supervisor to confirm your employment? Yes No
For a reference? Yes No
EDUCATION / MARRIAGE / TRANSPORTATION
Place an X in highest level of education completed:
___ High School
___ G.E.D.
___ Vocational Degree
___Associates Degree
___ 4 Year College Degree
___ Master’s or Doctor’s Degree
___ Other: Explain ______________
College Name: _________________________________ How many credit hours? ______________
What is your means of transportation? _________________________________________________
Circle One: Married
Single
Divorced
Separated
LEGAL
Have you ever been charged with a felony, but not convicted? Yes No
If “Yes”, what? ______________________ ______________________ ______________________
Have you ever been convicted of a felony? Yes No
Charge: __________________________________ Location: ______________________ Date: _________
Charge: __________________________________ Location: ______________________ Date: _________
Charge: __________________________________ Location: ______________________ Date: _________
Are there more than this? Yes No
Have you ever been arrested for a sex crime or arson? Yes No
How many times: ________
Charge: _________________________
Were you ever convicted? Yes No
Date:__________
Are you currently on parole? Yes No
Parole Officer’s Name: _________________________________ City & County: ___________________
Parole Officer’s Phone #: ______ - _______ - _________
Charge: _______________________________
Case #: _________________________________
Status: ____________________________________________________________________________
List any Court Charge(s) / Case(s) pending:
Charge: _______________________________
Case #: _________________________________
Status: ____________________________________________________________________________
Charge: _______________________________
Case #: _________________________________
Status: ____________________________________________________________________________
Charge: _______________________________
Case #: _________________________________
Status: ____________________________________________________________________________
Receiving SSI, Disability payments, or other Government Assistance: Yes No
Type: ____________________________
Amount: $___________ per ________ (week / month, etc.)
MEDICAL
Do you have any non-infectious physical conditions and/or diseases as diagnosed by a doctor? Yes No
Do you have any infectious physical conditions and/or diseases as diagnosed by a doctor?
Yes No
I have been diagnosed and have had the following prescribed to me by a doctor:
Diagnosis:_____________________ Prescription: ___________________ Dosage: ___________ per _____
Diagnosis:_____________________ Prescription: ___________________ Dosage: ___________ per _____
Diagnosis:_____________________ Prescription: ___________________ Dosage: ___________ per _____
Diagnosis:_____________________ Prescription: ___________________ Dosage: ___________ per _____
Diagnosis:_____________________ Prescription: ___________________ Dosage: ___________ per _____
Are there more than these? Yes No
I am currently taking the following over-the-counter medications and/or supplements:
Diagnosis:_____________________ Prescription: ___________________ Dosage: ___________ per _____
Diagnosis:_____________________ Prescription: ___________________ Dosage: ___________ per _____
Diagnosis:_____________________ Prescription: ___________________ Dosage: ___________ per _____
Are there more than these? Yes No
Sexually Transmitted Diseases:
When was the last time you were tested for all sexually transmitted diseases? __________________
What were the results?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Have you ever considered suicide before? Yes No
How many times? ________
Most Recent Date: ________
Have you ever attempted suicide before? Yes No
How many times? ________
Most Recent Date: _________
If so, explain:
______________________________________________________________________________________
______________________________________________________________________________________
If you answered “Yes” to any suicide based question, do you agree to enter into and submit to a suicide
contract if suicidal tendencies are witnessed? Yes No
Do you have any allergies, including allergies to medication? (If so, list)
__________________________ ____________________________ ___________________________
__________________________ ____________________________ ___________________________
__________________________ ____________________________ ___________________________
ADDICTION:
Circle “Yes” if you’re addicted to the following.
Circle “No” if you do not have a problem.
Check “Maybe” if you are not sure.
Alcohol ------------------------------------------------------------------------------------------- Yes
No
Maybe
Porn: ----------------------------------------------------------------------------------------------- Yes
No
Maybe
Soft Core Porn: (May also include ‘drinking in’ such things as Maxim type magazines, sex scenes, Etc.) --- Yes
No
Maybe
Sex: (Includes the following)
With other People: ------------------------------------------------------------------------ Yes
No
Maybe
I Pay for Sex: -------------------------------------------------------------------------------- Yes
No
Maybe
With Self (masturbation) -------------------------------------------------------------------- Yes
No
Maybe
With Non-Humans ------------------------------------------------------------------------ Yes
No
Maybe
Lust: (whether fantasizing about women, sex, money, or anything else which you desire but don’t have) ---- Yes
No
Maybe
TV: -------------------------------------------------------------------------------------------------- Yes
No
Maybe
Time on any Type of Computers Including Cell Phones: ------------------------------ Yes
No
Maybe
Video Games: ------------------------------------------------------------------------------------ Yes
No
Maybe
Spending Money: ------------------------------------------------------------------------------- Yes
No
Maybe
Gambling: ----------------------------------------------------------------------------------------- Yes
No
Maybe
Food: ----------------------------------------------------------------------------------------------- Yes
No
Maybe
Other Addictions: __________________________________________________________________
Drug(s) of Choice: __________________________________________________________________
Age of First Use: ______________ Date of last Use? ___________
Approx # of relapses in last year: _________
Longest period sober? ___________________ How long ago? _______________________________
What is the furthest step you’ve completed in:
AA? ________ NA?_________ SA?_________
Another 12 Step Program: ___________ Type: ______
Have you ever received any DUI's or DWI's or other intoxicated charge? Yes No How many? ______
Date of last DUI or DWI? ______________
Do you have a sponsor? ________
Sponsor’s Name/Telephone: __________________________
Do you give us (and your sponsor) approval for your sponsor to speak to us about you? Yes No
Previous Halfway House / Sober Living / Other Transitional Housing (not counting treatment or detox):
#1 Name:________________________
Length of Stay: _____________
Reason for Leaving: _______________
Date:_____________________
#2 Name:________________________
Reason for Leaving: _______________
Length of Stay: _____________
Date:_____________________
#3 Name:________________________
Reason for Leaving: _______________
Length of Stay: _____________
Date:_____________________
Were there more than these? (circle one): Yes
No If so, how many more?: ______________
Sober Living:
Treatment / Detox Programs Attended? (List)
_____________________________________________ Date: ________________ Completed: Yes No
_____________________________________________ Date: ________________ Completed: Yes No
_____________________________________________ Date: ________________ Completed: Yes No
_____________________________________________ Date: ________________ Completed: Yes No
_____________________________________________ Date: ________________ Completed: Yes No
_____________________________________________ Date: ________________ Completed: Yes No
What, if any, are your after-care requirements? ____________________________________________
Most Recent Counselor/caseworker: _________________________ Phone #: ___________________
Attitude / Participation / Cooperation:
Do you have any problems with rules or authority? Yes No
Are you willing to take on House offices? (President / Treasurer / Etc.) Yes No
Are you willing to take on chores? Yes No
Are you willing to volunteer 2hrs/week to help with neighbors and the betterment of the House? Yes No
Are you prejudiced towards any group or race? ________________________________________
Have you ever been violent: Yes No
Last Time to be Violent: ________________
Have you ever been charged with a violent crime? Yes No
Have you ever been convicted of a violent crime? Yes No
If so, explain:
______________________________________________________________________________________
______________________________________________________________________________________
Is there anything else you feel we should know about you?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
EMERGENCY:
____________________________ (_____)_______-__________
Name
Phone
__________________
Relationship
____________________________ (_____)_______-__________
Name
Phone
__________________
Relationship
____________________________ (_____)_______-__________
Name
Phone
__________________
Relationship
All information above is true to the best of my knowledge. Into Action, LLC may use this information in
any way necessary to determine if I shall be a qualified candidate for entry onto Into Action, LLC property.
PRINT NAME: _______________________________________________________________
SIGNATURE: X________________________________________DATE:__________________