Sober Living Application

Kyle's House, Lacey's House, MS Recovery House, & Prosperity House Application

Welcome to the Sober Living intake wizard for Kyle's House (Men Only), Prosperity House (Men Only), MS Recovery House (Men/Women), & Lacey's House (Women Only)

For any issues, please contact Jeremy @ 662-231-3823 or soberlivingtupelo@gmail.com

Please fill the application in full. Lack of information could cause delays and opens the potential for losing an open bed. 

Click next to begin!

General

Tell us about yourself
What is your first name?
Client first name
What is your middle name? No middle name? Move on to the next question.
Client middle name
What is your last name?
Client last name
When is your birthdate?
Client birthdate
What is your race/ethnicity?
Client race
What is your gender?
Client gender
What is your marital status?
Client marital status
Are you a veteran?
Client veteran
Do you have any Criminal History? 
Text field
Are you currently on Drug Court or under any other Court requirements?
Radio buttons
If so, please elaborate:
Text field
Have you been convicted of Murder, Rape, or Arson?
Radio buttons
Are you on parole?
Radio buttons
Are you on Suboxone, Methadone, or any other MAT program?
Radio buttons
What is your requested admit date?
Client admit date

Contact Information

How can we reach you?
What is your email address?
Client email
At what phone number can we best reach you at?
Client phone
Home Street Address:
Client Address
City:
Client City
State:
Client State
Zipcode:
Client Zip

Contacts

Give us a few people that we can reach out to in case of an emergency.
Contact
Contact

 

Medical History

Tell us about your medical history.
When was your last relapse date?
RecoveryHistory
What is your substance(s) of choice? Add multiple by clicking in the box and selecting different options
Client substances of choice
Have you been clinically diagnosed with anything? Add multiple by clicking in the box and selecting different options
Client diagnosis
Do you have any health problems? Add multiple by clicking in the box and selecting different options
Client health problems
What kind of meetings do you attend? Add multiple by clicking in the box and selecting different options
Client kinds of meetings attended
What allergies do you have? No allergies? Move on to the next question.
Client allergies
 

Medications

List the medications you are currently prescribed.
Medication

Treatment Centers

Tell us about any treatment centers you've previously been admitted into.
TreatmentCenterHistory

Client Referral Source

 
Who referred you to us?
Client Referred By

 

 

Sober Living History

Tell us about any sober livings you've previously been admitted into.
SoberLivingHistory

Employment

Tell us about your employment status.
If you're currently unemployed select "unemployed" under "type"

EmploymentHistory

 

Fee's & Upfront Costs

To reserve a bed, you understand that a non-refundable $250 deposit and the first months dues are required. An invoice email will be sent to you upon completion of this applicatoin unless other arrangements have been made. 

Checkboxes

Monthly due's are $700/month for Kyle's House and Prosperity House.

Monthly due's are $800/month for Lacey's House.

Living Arrangement

Tell us about your living arrangement prior to moving into this facility

LivingArrangementHistory

 

No Refund Policy

No Refund Policy

One Step Requirement

One Step Requirement