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House Application
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Preliminary Application
First name
*
Last name
*
Phone
Birthday
Month
Month
Day
Year
Previous Sober Living Facilities. Please include inpatient treatment facilities
Drug of Choice and Current Length of Time in Recovery (Must pass a Urine Drug Screen to Move In)
*
Current clinical treatments and recovery programs
*
Current Clinical Providers and Medications
*
Are you on probation or do you have pending legal issues? (Include name of PO, if you are in Drug Court, or any other information you feel we should know)
*
Emergency Contact Name and Phone Number
*
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Rental Agreement
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