SPEED UP THE PROCESS

COMPLETE 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 *

    Sobriety Date *

    Previous Treatment Centers *

    Previous Sober Living *

     

    Legal Information


    On Parole *

    On Probation *

    Charges Pending *

    Registered Sex Offender *

    If Yes Above, Please Describe

     

    Medical Information


    Have Medical Insurance *

    Insurance Provider

    Prescription Medications *

    Doctor's Name

    Doctor's Phone

    Previous Suicide Attempt *

    Allergies/Conditions *

     

    Employment Information


    Currently Employed *

    Able to Work *

    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 *