Sober Living Men’s Intake Application

Have you had a substantial period of sobriety (4 months or more) or have successfully completed a long-term program?

Were you previously a member/resident of The Way Recovery Houses?

Name

First Name

Last Name

Date

YYYY

Date Of Birth

YYYY

Mobile Phone

(###)

###

####

Address

Valid Drivers License / State ID

Drivers License / State ID Number

Emergency Contact

Relationship to Emergency Contact

Contact Number

(###)

###

####

Address

Relationship Status

Significant Other

Mobile Phone

(###)

###

####

Address

Names Of Children

Ages of Children

Parole / Probation Officer

Mobile Phone

(###)

###

####

County And State

Pending Charges

Fines / Costs / Restitution

Prior Charges

Registered Sex Offender

Employer

Contact Number

(###)

###

####

Occupation

Monthly Salary

Additional Income

Monthly Amount for Additional Income

Highest Education

Military Service

Place of most recent Drug, Alcohol, Mental Health Treatment

Date of Release from Treatment

YYYY

Successful Discharge from Treatment

Sobriety / Clean Date

YYYY

List All Mental Health Diagnosis

List All Phsyical Limitations

What was your childhood like?

What Faith were you raised in?

When did you start using or drinking?

When did you realize that using or drinking was a problem?

What led you to The Way Recovery Houses?

Sober Living Men’s Intake Application

Call us now at (717) 525-5701

location

3545 Marietta Avenue Suite W

Lancaster PA 17601

women’s program

amartin@thewayrecoveryhouses.com

Men’s program

scornell@thewayrecoveryhouses.com

Director

director@thewayrecoveryhouses.com

Follow

Sober Living Men's Intake Application

Sober Living Men’s Intake Application

location

3545 Marietta Avenue Suite W

Lancaster PA 17601

women’s program﻿

amartin@thewayrecoveryhouses.com

Men’s program

scornell@thewayrecoveryhouses.com

Director

director@thewayrecoveryhouses.com

Follow

women’s program