Intake Form - Complete Form
Do you have a car you will be bringing to the house?*
Do you have a driver's license?*
Do you currently have health insurance?*
Are you currently on probation or parole?*
Have you been convicted of a violent crime?*
Have you been convicted of a sex related crime?*
Have you ever been convicted of Arson?*
Have you ever experienced an Overdose?*
Have you ever had a Heart Attack or Stroke?*
Have you been to AA or any 12 Step based fellowship?*
Are you willing to engage in 12 Step Meetings? Getting a sponsor, commitment, working the 12 steps and finding a home group.*
Have you been in Sober Living?
Emergency Contact Relation to You*
