Apply | Beverly's Light Sober Living

Applicant Information

Full Name *

Date of Birth *

Gender *

Phone Number *

Email *

Current Address *

Emergency contact: Name, Relationship, Phone Number *

Recovery Information

Primary Drug(s) of Choice *

Last Date Used / Sobriety Date *

Currently in treatment? *

Yes
No

Referral Source *

Counselor/Agency/Phone *

Employment

Employment Status *

Employer *

Monthly Income *

Legal Information *

Probation
Parole
Drug Court
None

Officer *

Phone *

Medical Information

Primary Care Physician *

Medical Conditions *

Current Medications *

Medication Managment Needed? *

Yes
No

Mental Health

Diagnosis (if any) *

Recovery Comitment

I agree to maintain sobriety, follow house rules, attend required recovery meetings, participate in random drug/alohol screening, maintain a clean living environment, treat others respectfully, and pay program fees as agreed.

Required Documents

Photo ID, Insurance Card (if applicable), Medication List, Emergency Contact Information, Referral Paperwork (if applicable)

Applicant Certification

I certify the information provided is true and complete.

Applicant Signature: *

Date *

Send me a copy