Last Name
First Name
Middle Name
Date of Birth

Last Permanent Address:

Street
City
State
Zip Code
Best phone number to reach you
Alternate Phone Number
Email
Emergency Contact
Relationship
Phone
Marital Status
 
Are you an alcoholic?
Yes
No
Date of last drink
Are you addicted to drugs
Yes
No
Date of last drug use
List drugs you have used addictively (separate by comma)
When did you attend your first AA/NA meeting?
How many AA/Na meetings do you attend each week?
Sponsor
Homegroup
Have you ever been to a treatment facility? Yes
No
 

If so, provide the following:

Facility Name
Date
Counselor's Name
Phone
List of current prescribed medication(s)
And reason it is prescribed

If you have a doctor provide the following:

Name
Phone

Are you employed? Yes

No
Number of hours per week
Employer
Monthly Income
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.
Date