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 Provider Prescription Medications * Doctor's Name Doctor's Phone Previous Suicide Attempt * NoYesAllergies/Conditions * Employment InformationCurrently Employed * NoYesAble to Work * NoYesEmployer'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 * 4-1=?