Four County Transitional Living


Application Form


Enter your information as thoroughly as possible in the form below, then hit submit to apply for residency. Note:Fields Marked with Required Field Indicator Are Required
Your details
  1. Please enter your full name

  2. Please enter your date of birth as mm/dd/yy

  3. Please enter your full address, with apt #

  4. Please enter your city

  5. Please enter your state

  6. Please enter your zip code. 5 numbers optionally followed by an additional 4 numbers; either 12345 or 12345-1234.

  7. Please enter your Phone Number e.g. 123-123-1234.

  8. Please enter a valid email address e.g. name@example.com

Current Condition Information
  1. What do you hope to achieve?

  2. Have you been clean and sober for at least 72 hours?

    Please click yes or no

    1. Please enter your date of your last drink in mm/dd/yy format

    1. Please enter your date of your last drug usage in mm/dd/yy format

    2. Ever attend Alcoholics Anonymous or Narcotics Anonymous?
    3. Do you have a sponsor?
Legal Questions Section
  1. Are you involved in any legal action at this time?
  2. Are you currently on probation?
  3. Is your stay here, if approved, going to be under court order?

  4. Please enter your date of your court order obligation completion in mm/dd/yy format

Commit to Recovery Section
  1. Have you made a commitment to stop drinking and /or using drugs?
  2. Are you willing to commit to stay at 4CTL for 270 days?
  3. Have you ever lived in a recovery house?
Employment and Financial Section
  1. Are you employed?
  2. If unemployed: are you willing to get a job?
  3. Do you receive unemployment, disability, pension or any other income
Emergency Contacts
Please list two (2) people to contact in the case of emergency:
  1. First Emergency Contact
    1. Enter full name of first emergency contact

    2. Enter address of first emergency contact

    3. Enter relationship of first emergency contact

    4. No spaces or brackets e.g. 123-123-1234

  2. Second Emergency Contact
    1. Enter full name of second emergency contact

    2. Enter address of second emergency contact

    3. Enter relationship of second emergency contact

    4. No spaces or brackets e.g. 123-123-1234

  3. Physician's Information:
    1. Enter the name of your of your primary physician

    2. Enter address of your primary physician

    3. No spaces or brackets e.g. 123-123-1234

  4. List any additional information that would be helpful for us to know during your stay:


  1. I HAVE READ AND UNDERSTAND THE HOUSE RULES AS STATED ABOVE AND AGREE TO COMPLY AS A CONDITION OF MY ADMITTANCE.
  2. FOUR COUNTY TRANSITIONAL LIVING ENFORCES IMMEDIATE EXPULSION IF ANY RESIDENT IS:

    • Found to be using alcohol or drugs.
    • Is non-compliant with the House Rules.

    I agree with all of the above statements, I waive any Resident rights while an occupant at Four County Transitional Living, Inc.

    I agree that 4CTL or its agent may use the above information for a background check.