Your Name *
Street Address *
City *
State *
Zip Code *
Phone *
Your Email *
Contact Name *
Contact Number *
Contact Relationship *
Substances Abused * HeroinCrackOxycontinAlcoholMarijuanaPercosetPillsMethCocaineKetamineEcstasyOtherNot Sure
Sobriety Date *
Previous Treatment Centers *
Previous Sober Living *
On Parole * NoYes
On Probation * NoYes
Charges Pending * NoYes
Registered Sex Offender * NoYes
If Yes Above, Please Describe
Have Medical Insurance * NoYes
Insurance Provider
Prescription Medications *
Doctor's Name
Doctor's Phone
Previous Suicide Attempt NoYes
Allergies/Conditions *
Currently Employed * NoYes
Able to Work * NoYes
Employer's Name
Supervisor's Name
Shift Start Time
Shift End Time
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. *
