Living in Recovery ApplicationOnce the application is completed, please call our office for an interview at 443-741-1331. 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 (###) ### #### Email * Emergency Contact * First Name Last Name Relationship * Emergency Contact Phone Number * (###) ### #### Gender Male Female Non-Binary Prefere Not To Say Race American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander Unknown White Ethnicity Hispanic or Latino Not Hispanic or Latino Unknown Marital Status * Single Married Divorced Separated Widowed 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 How Many AA/NA Meetings do you Attend Each Week? 0 1 2 3 4 5 6 7 7+ Sponsor Homegroup Have you ever been in Treatment? * YES NO If Yes, what Facility? Intake Date Counselor's Name First Name Last Name Facility Phone Number (###) ### #### List of Current Prescribed Medication(s) What is the Reason Medication(s) is Prescribed? EMPLOYMENT Are You Currently Employed? * Yes No If Yes, How Many Hours a Week do You Work? Name of Employer Monthly Income Please add as a number. 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 Date MM DD YYYY Thank you!
