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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 *