Application Form
Thank you for your interest! Please take a moment to fill out this information so we can look at helping you with next steps! 🙏
Name of Client
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First Name
Last Name
How did you hear about us?
*
What is your desired Arrival date?
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Age:
*
Date of Birth:
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-
Month
-
Day
Year
Date
Sober Date:
*
Drug of Choice:
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What medications do you take?
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Do you have any Mental Health Diagnosis?
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Do you have any open legal issues, court dates, or charges pending?
*
What is your main goal or focus you want to achieve while living here in sober living?
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Have you ever had any self injurious behaviors, like cutting or suicidal ideations? (If so, when was the last attempt?)
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Do you have any past psychiatric hospital stays, or treatment center history?
*
Are you a registered sex offender?
*
Name of the Person Responsible for Payment?
*
First Name
Last Name
Phone Number of the Person Responsible for Payment
*
Please enter a valid phone number.
Format: (000) 000-0000.
Lastly, are you willing to work with a sponsor and go to a minimum of 3 AA affiliated meetings a week in order to live here?
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Yes
No
Are there any other concerns or questions that you might have? Please let me know! Thank you for taking the time to fill this out, and I’ll talk with you soon!
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Submit
Should be Empty: