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Apply for Sober Living

Application

Type of Room Requested
Please select your desired room choice.
General Information
Full Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth
Enter your Date of Birth
MM slash DD slash YYYY
Phone
Best Email
Which gender do you mostly identify with?
Which gender do you most identify with?
What is your martial status?
What is your martial status?
Emergency Contact
Full 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
MM slash DD slash YYYY
Longest Time Sober
Substances Used/Abused
Are you Discharging from a Substance Abuse Facility?
Please Select if you are Discharging from Another Substance abuse facility.
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)
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?
How did you hear about us?
Please explain how you heard about us.
Referral Type:
Referral Type:
- Treatment Center
- Hospital
- Internet Search
- Healthcare Provider
- Sponsor
- Family or Friend
Medical Information
Other than addiction, are you being treated for any other physical or mental conditions?
Other than addiction, are you being treated for any other physical or mental conditions?
If yes, please describe:
If yes, please describe:
If you are taking prescribed medications, please list the name, dosage, and purpose of each, below.
If you are taking prescribed medications, please list the name, dosage, and purpose of each, below.
Other Information
Will You Be Bringing a Vehicle?
If so, please provide year, make, model and color:
If so, please provide year, make, model and color:
Will you be using Private Insurance to pay for IOP services?
Will you be using Private Insurance to pay for IOP services?
Provide insurer and type (PPO/MHO):
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.
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.
Phone
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Application

General Information

Emergency Contact

Legal Information

Substance Use History

How did you Hear About Us?

Medical Information

Other Information