Application for Bed Space — Noho'ola Kupa'a

Section 1 — Basic Information

Date of Application

Desired Move-In Date

Section 2 — Personal Information

Full Name *

Date of Birth *

Phone *

Current Address *

Emergency Contact Name

Emergency Contact Phone

Relationship to Emergency Contact

Section 3 — Employment & Income

Employment Status

Employed Unemployed Student Other

If Other, please specify:

Employer

Position / Job Title

Monthly Income ($)

Additional Income?

Yes No

If yes, describe source and amount:

Section 4 — Substance Use History

Are you currently sober? *

Yes No

If yes, length of sobriety:

Primary Substance(s) Used

Have you completed a treatment program?

Yes No

If yes, where and when:

Are you currently in a recovery program (AA / NA / counseling)?

Yes No

If yes, describe:

Section 5 — Health & Wellness

Do you have any medical conditions?

Yes No

If yes, please describe:

Are you currently prescribed any medications?

Yes No

If yes, list medications:

Do you require mental health care or support?

Yes No

If yes, describe your needs:

Section 6 — Program Expectations

By submitting this application, I agree to the following conditions of residency:

Maintain sobriety at all times while residing at Noho Ola Kūpaʻa Participate in required house meetings, group sessions, and assigned chores Show respect to all residents, staff, and property at all times Follow all house rules as outlined in the Resident Handbook

Section 7 — Personal Goals

Why are you applying and what are your recovery goals?

Section 8 — References

Please provide two personal or professional references (not family members).

Reference 1

Name

Phone

Relationship

Reference 2

Name

Phone

Relationship

Section 9 — Applicant Certification

I certify that all information provided in this application is true and accurate to the best of my knowledge. I understand that any false or misleading information may result in the disqualification of my application or termination of my residency.

Printed Name *

Signature *

Date *

After submitting, Lisa will contact you at the phone or email you provided within 1–2 business days.
Questions? Call 808-264-0009 or email lisapereira@nohoolakupaa.org

Noho Ola Kūpaʻa Sober Living Facility