SPEED UP THE PROCESSCOMPLETE OUR ONLINE INTAKE FORM Contact InformationYour Name *Street Address *City *State *Zip Code *Phone *Your Email * Emergency ContactContact Name *Contact Number *Contact Relationship * Drug/Alcohol & Treatment HistorySubstances Abused *HeroinCrackOxycontinAlcoholMarijuanaPercosetPillsMethCocaineKetamineEcstasyOtherNot SureSobriety Date *Previous Treatment Centers *Previous Sober Living * Legal InformationOn Parole *NoYesOn Probation *NoYesCharges Pending *NoYesRegistered Sex Offender *NoYesIf Yes Above, Please Describe Medical InformationHave Medical Insurance *NoYesInsurance ProviderPrescription Medications *Doctor's NameDoctor's PhonePrevious Suicide Attempt *NoYesAllergies/Conditions * Employment InformationCurrently Employed *NoYesAble to Work *NoYesEmployer's NameSupervisor's NameShift Start TimeShift 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=?