Apply for Sober Living

Burning Tree West Sober Living

Do you want a single room to yourself or do you want to share a room?

Single Room, $1,500 per month
Shared Room, $1,000 per month

General Information

Name

Address

Date of Birth

Phone

Best Email

What is your martial status?

What is your marital status?

Single
Married
Widowed

Emergency Contact

Name

Phone

Email

Relationship

Legal Information

Are you currently on probation or have pending charges? (Please provide detailed information):

Have you ever been convicted of any felonies?

Substance Use History

Sobriety Date

Longest Time Sober

Substances you used/abused (check all that apply)

Other Drugs Used Not Listed:

Are you discharging from a substance abuse facility?

Yes
No

If yes, what treatment center are you discharging from?

Treatment History: please list the treatment centers you have been to and the year you admitted. (Including detox, RTC, IOP, and sober livings)

How did you Hear About Us?

Referral Type:

Treatment Center
Hospital
Internet Search
Healthcare Provider
Sponsor
Family or Friend

Hear About Us From Somewhere Else?

Medical Information

Other than addiction, are you being treated for any other physical or mental conditions?

Yes
No

If yes, please describe:

If you are taking prescribed medications, please list the name, dosage, and purpose of each, below.

Other Information

Will you be bringing a vehicle?

Yes
No

If so, please provide year, make, model and color:

Will you be using Private Insurance to pay for IOP services?

Yes
No

Provide insurer and type (PPO/MHO):

I, the undersigned, submit that the information contained herein is true to the best of my knowledge and accept that false information or omissions of information may cause services with Burning Tree West to be terminated. Please type your name.

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Application