Online Intake

Take the first step toward a life of freedom!

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 Way of Life, LLC may utilize the information in rendering a decision on my acceptance into the sober living program they facilitate. *