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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. *