Your Name (required)

Your Email (required)

Date of Birth

Clean/Sober Date

Phone

Insurance Information

List allergies

List prescribed medications

Are you on a suboxone, methadone or vivitrol maintenance program? If so who is your prescribing doctor and what is your current dose?

Are you currently in treatment? What is the name of treatment center, counselor’s number and e-mail. If not in treatment when was your discharge date?

What is your primary concern substance use disorder or mental health?

How do you plan on paying?

Sponsor

Home group

Are you bringing a vehicle? If yes, please provide make, model, color and tag #

How willing are you to do whatever it takes to keep your recovery first?

What do you currently think and believe about your addiction?

Have you ever been asked to leave another recovery house? If so, please explain?

Length of time you plan on staying in a recovery house?

Have you ever been convicted of a felony or misdemeanor? If so, please explain.

If you are currently on probation, please provide name and number of your P.O.

Where have you lived the past two years?

Have you been accused of or convicted of any sex offense? If so, please explain.