Rise & Recover Sober Living
New Resident Application
Full Name
*
First Name
Last Name
What is your date of birth?
mm/dd/yyyy
What is your gender?
*
Please Select
Male
Female
N/A
What is your shirt size?
*
Please Select
Small
Medium
Large
XL
2XL
3XL
4XL
All new residents will receive a Rise & Recover Sober Living t-shirt!
Contact Number
*
Format: (000) 000-0000.
Emergency Contact
*
First Name
Last Name
Emergency Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Are you expecting to experience any withdrawal symptoms?
Yes
No
Are you currently attending treatment?
*
Yes
No
I would like to
Name of Treatment Provider
*
You have the right to choose your own treatment provider
Which location would you like to apply to?
*
Fairfield
Middletown
Fairborn
Springfield
Dayton
Marietta
Vincent
Cincinnati
Date of last substance usage:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: