Book An Appointment Step 1 of 7 14% Personal InformationName(Required) First Last Phone(Required)Email(Required) What is your gender? We ask only for room availability purpose.(Required)Please SelectMaleFemaleWhat is your date of birth?(Required) MM slash DD slash YYYY AddressDid anyone refer you to us? Their name so we can tell them thank you. Employment and Financial ResponsibilityAre you currently employed?(Required) Yes No What is your monthly salary?(Required)How do you pay for living expenses?(Required)Are you able to meet the financial obligations of living in this housing (e.g., rent)?(Required) Yes No Substance Use and RecoveryWhat substances have you used in the past?(Required)what is your sobriety date?(Required) MM slash DD slash YYYY Have you completed a 12-Step program before?(Required) Yes No what steps are you currently taking to maintain your sobriety (e.g., attending meetings, counseling, etc.)?Are you actively participating in an Intensive Outpatient Program (IOP)?(Required) Yes No which facility?(Required)do you plan on attending an IOP?(Required) Yes No Housing and SupportHave you ever lived in a sober living or transitional housing home before?(Required) Yes No If so, please describe your experience.(Required)Do you have a support network (friends, family, sponsors) in place to help you during your transition?(Required) Yes No Goals and ExpectationsWhat are your goals for the next 6 months to 1 year while living in sober or transitional housing?(Required)Are you willing to adhere to the house rules and participate in any required programs or meetings?(Required) Yes No Mental HealthDo you have any mental health diagnoses?(Required) Yes No if so, are you currently receiving treatment?(Required) Criminal HistoryDo you have any of the following criminal history?(Required) Homicide Assault Robbery/Theft Rape and Sexual Assault Aggravated Assault Kidnapping Domestic Violence None of the above UntitledUntitled Δ