Living in recovery application

Please fill out this application as accurately as possible and someone from our organization will be in contact with you shortly.

Name *
Name
Date Of Birth *
Date Of Birth
Last Permanent Address *
Last Permanent Address
Best Phone Number *
Best Phone Number
Alternate Phone Number
Alternate Phone Number
Emergency Contact *
Emergency Contact
Emergency Contact Phone Number *
Emergency Contact Phone Number
Are You An Alcoholic? *
Are You Addicted To Drugs? *
Have You Ever Been To A Treatment Facility? *
Counselor's Name
Counselor's Name
Facility Phone Number
Facility Phone Number
IF YOU HAVE A DOCTOR, PLEASE PROVIDE THE FOLLOWING:
Doctor's Name
Doctor's Name
Doctor's Phone Number
Doctor's Phone Number
EMPLOYMENT
Are You Currently Employed? *
This information will be used only for the purpose of selecting residents for a Living in Recovery, Inc. house. The undersigned states that all information is accurate and hereby authorizes Living in Recovery, Inc. and/or its agents to conduct credit and criminal background checks. *