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Program Application

Please complete the form below to apply for the New Leaf Sober Living program

First Name

Last Name

Birthday

Email

Phone Number

Current or Most Recent Street Address

Current Street Address Line 2

City

Region/State/Province

Postal / Zip code

Country

Do you have an alcohol problem? * Required

Yes

No

Date of last drink:

Do you have a drug problem? * Required

Yes

No

Date of last use:

Do you want to stop drinking/using? * Required

Yes

No

How many recovery meetings do you attend per week?

Currently in Treatment or Facility?

Facility Name

Facility Phone Number

Facility Address

Employment Status: *

Full-time

Part-time

Unemployed

Employment Monthly Income:

Are you receiving other types of income? (retirement, disability, family, welfare, etc.)

Other monthly income:

Marital Status * Required

Single

Married

Separated

Divorced

Widow

Medical doctor name:

Medical doctor phone number:

Mental health professional name:

Mental health professional phone number:

Name of last treatment center/detox:

Number of times in treatment/detox:

List all medications you are currently taking/prescribed:

Desired move-in date:

Have you previously lived in a sober living house? *

Yes

No

If yes, list the house name:

If yes, what was the reason for departure?

Voluntary

Relapse

Disruptive Behavior

List 3 emergency contacts (name, relationship, and contact info):

Please share any relevant information related to your active addiction and/or recovery with us, including why you want to live here:

Thanks for submitting!

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