Sober Living House Application Form
Apply for admission to our sober living house. Please provide the information below to help us evaluate your housing readiness and placement needs.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Current Living Situation
*
Own home/apartment
With family or friends
Shelter or transitional housing
Homeless
Other
Gender
*
Male
Female
Non-binary
Prefer not to say
Other
Employment or School Status
*
Employed full-time
Employed part-time
Unemployed
In school
Other
Briefly describe your reason for seeking admission
*
Have you lived in a sober living house before?
*
Yes
No
Emergency Contact Name and Phone
*
Submit Application
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