Apply Now Name * First Name Last Name Age Select One... 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 Phone (###) ### #### Email Expected Move in Date * Provided a bed is available, what is your ideal move in date? MM DD YYYY Substances Used * Please select substances used in the last 3 months. Select all that apply. Alcohol Opiates Benzodiazepines Cocaine Hallucinogens Stimulants Inhalents Other None Current Treatment * Are you currently in a treatment facility of any kind? Select One... Detox Treatment Center Sober Living PHP IOP No If so, please provide the name of the facility, and contact information for your case manager. Treatment History Please list treatments attended in the last 5 years. (Detox, 30-90 day programs, PHP, IOP, Sober Living) 12-Step Experience * Do you have any experience with the 12-Steps of Alcoholics Anonymous? Select One... Yes No Medical Conditions Please provide a list of current medical conditions Medications Please list any medications you are currently prescribed, if any. Legal Status * Do you have any past/present legal issues? Select One... Yes, current Yes, past No Sex Offender Status * Are you required to register as a sex offender? Select One Yes No How do you intend on paying for sober living? * Select all that apply Savings Parents/Family Assistance Outside Scholarship Government Assistance I am willing to commit to 3 months of sober living * Agree I agree to communicate any changes to the information provided * Agree Thank you! We will reach out to you shortly!
