SPEED UP THE PROCESSCOMPLETE OUR ONLINE INTAKE FORM Contact Information Your Name * Street Address * City * State * Zip Code * Phone * Your Email * Emergency Contact Contact Name * Contact Number * Contact Relationship * Drug/Alcohol & Treatment History Substances Abused * HeroinCrackOxycontinAlcoholMarijuanaPercosetPillsMethCocaineKetamineEcstasyOtherNot Sure Sobriety Date * Previous Treatment Centers * Previous Sober Living * Legal Information On Parole * NoYes On Probation * NoYes Charges Pending * NoYes Registered Sex Offender * NoYes If Yes Above, Please Describe Medical Information Have Medical Insurance * NoYes Insurance Provider Prescription Medications * Doctor's Name Doctor's Phone Previous Suicide Attempt * NoYes Allergies/Conditions * Employment Information Currently Employed * NoYes Able to Work * NoYes Employer's Name Supervisor's Name Shift Start Time Shift End Time Acceptance & Verification I hereby certify that the information above is true and accurate and that Independence Lodge may utilize the information in rendering a decision on my acceptance into the sober living program they facilitate. * I'm Human * 1+3=?