INTAKE FORM

Name

Date of Birth

Email Address

Clean Date

Phone Number

List of Allergies

List of Medications

How do you plan on paying?

Sponsor?

Home group?

Do you plan on bringing a vehicle? (if yes please provide make, model, color, tag #

Length of time you plan on living in recovery house?

Have you ever been asked to leave another house? (if yes, explain)

Currently on probation or any open criminal charges?