Sober Bridge Application Form
Heading
Please complete this confidential application to begin the intake process at Sober Bridge Living.
Name
*
First Name
Last Name
Email Address
*
example@example.com
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please upload a clear photo of a valid government‑issued ID. Accepted forms of ID include: Driver’s License, State ID, Passport, or Government ID. The name on the ID must match the name on this application. This is required for safety, identity verification, and residency approval.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Preferred Move-In Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Referral Source
*
Please Select
Self
Treatment Center
Therapist
Probation
Case Manager
Family Mamber
Other
Current Living Situation:
*
Recovery Journey & Goals
*
Room Preferance
Private room
Semi-Private Room
No Preference
Signature
*
Date Signed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
SUBMIT
SUBMIT
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Should be Empty: