Sober Living Providers
This form should only be filled out by someone affiliated with the recovery home only!
Name of sober living home?
*
Website of sober living
Social Media Page of sober living
Address of sober living home
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you currently licensed under Arizona Department of Health Services?
*
Yes
No
If yes, please include your license number
*
What are your sober living requirements you expect out of each resident? (Include AA/NA meetings, UA test, curfew, house meetings, etc...)
*
Do you offer promise to pay?
Yes
No
Role with organization
*
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
How many homes are affiliated with you organization?
*
Please list names of homes, address, and occupancy of affiliated homes
*
What are your fees for all homes? (Please include weekly fees, application fees, deposit fees, or any other fees)
*
Do you house (select all that apply)
*
Men
Women
Familes with children
Women with children
Father with children
If you house children what is the cap for children?
*
What precautions do you take to keep the children safe?
*
Are you a 12-step recovery-based program?
*
Yes
No
Do you provide UA test?
*
Yes
No
Do you require residents to go to IOP/PHP?
*
Yes
No
Do you accept individuals on Medication-Assisted Treatment?
*
Yes
No
Do you provide on-site housing managers?
*
Yes
No
What other programs/assistance do you offer residents?
*
Submit
Should be Empty: