Sober Living | Admission

	Name:
	Email (required):
	Date of Birth:
	Permanent Address:
	City:
	State:
	Zip:
	Phone #:
	Social Security #:
	Marital Status:	Married Single Divorced Separated
	Number of Children:
	Childrens' Names and Ages:
	Where Do They Live?:
	Driver's License #:
	License Plate #:
	Insurance Policy #:
	Emergency Contact Information
	Name:
	Relationship:
	Phone #:
	Address:
	City:
	State:
	Zip:
	Employment
	Emplolyer:
	How Long?:
	Position:
	Address:
	City:
	State:
	Zip:
	Sober History
	Sobriety Date:
	Last Treatment Center:
	Address:
	City:
	State:
	Zip:
	Therapist:
	Phone #:
	Special Situations (Community Control, House Arrest, Probation)
	Contact:
	Phone #:
	Address:
	City:
	State:
	Zip:
	Aftercare
	Coordinator:
	Phone #:
	Meeting Times:
	Sponsor (optional):
	Sponsor's Phone #:
	Medications: (List all, including over the counter medications)
	Medicine #1:
	Dosage:
	Physician:
	Phisician Phone #:

	Medicine #2:
	Dosage:
	Physician:
	Phisician Phone #:

Medicine #3:
Dosage:
Physician:
Phisician Phone #:

Medicine #4:
Dosage:
Physician:
Phisician Phone #:

Medicine #5:
Dosage:
Physician:
Phisician Phone #:
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