Name *

First Name

Last Name

Date Of Birth *

MM

DD

YYYY

Last Permanent Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Best Phone Number *

(###)

###

####

Alternate Phone Number

(###)

###

####

Emergency Contact *

First Name

Last Name

Emergency Contact Phone Number *

(###)

###

####

Are You An Alcoholic? *

YES

NO

Date Of Last Drink

MM

DD

YYYY

Are You Addicted To Drugs? *

YES

NO

Date Of Last Drug Use

MM

DD

YYYY

Drugs You Have Used Addictively

Alcohol

Benzo

Cocaine

Crack

Heroine

Inhalants

K-2

Kratom

LSD

Marijuana

MDMA

Methamphetamine / Salts

Opiates

PCP

Stimulants

When Did You Attend Your First AA/NA Meeting?

MM

DD

YYYY

Have You Ever Been To A Treatment Facility? *

YES

NO

Counselor's Name

First Name

Last Name

Facility Phone Number

(###)

###

####

Doctor's Name

First Name

Last Name

Doctor's Phone Number

(###)

###

####

Are You Currently Employed? *

Yes

No

This information will be used only for the purpose of selecting residents for a Living in Recovery, Inc. house. The undersigned states that all information is accurate and hereby authorizes Living in Recovery, Inc. and/or its agents to conduct credit and criminal background checks. *

YES