Intake Form

6o3 Sober Living Intake

6o3 Sober Living is a 4-phased Sober Living Recovery Program; where residents will build their foundation on sobriety, work a program of recovery, and gain support through their local community. We are a faith-based Sober Living, and provide access to engage in Faith-Based Recovery; 12-Step Recovery; and various other forms of Recovery. Within the first 7-days of your stay in our sober house, the Leadership team will review your required recovery program and set you up for success!  

6o3 Sober Living does accept Medication Assisted Treatment and abstinent based sobriety, as well. Medications will be locked in a specific resident only combination lock box, and placed in a locked cabinet located in our locked medication/supply room. Medications will be observed by Leadership upon taking.

Weekly Program Fee is $225. Intake and Criminal Background Fee is $150. Weekly Program Fee is due by Sunday at 6pm. Weekly Program Fee includes: Heat/Electric/WIFI/Netflix/Disney+/Case Management Service.

We do accept funding through Southern NH Services; Community Action Partners, NHCORR, The Doorway, and the Herron Project.

Unfortunately, we cannot accept residents with violent major crimes such as sexual offenses, arson and some domestic violence. Please fill out the criminal record section and we will discuss together. A criminal background will still be run, prior to acceptance of your application and move in date.

We also take into consideration all reasonable accommodations. During your phone intake, this will be discussed at length. You may be asked to complete a formalized Reasonable Accommodation Form upon acceptance.

Click next to begin!


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
Do you have any children?
Tell us a little about your children. Are you able to see them? Do you have custodial rights? Any other information you'd like to share.
Are you a veteran?
Client veteran status

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
Last Known Street Address:
Client Address
Client City
Client State
Client Zip

Emergency Contacts

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



Enter your insurance provider(s). We do not accept or require you to have insurance. We will assist you in obtaining insurance, if needed. 


Medical History

Tell us about your medical history.

Do you have any health problems? Add multiple by clicking in the box and selecting different options
Client health problems
What allergies do you have? No allergies? Move on to the next question.
Client allergies
Last known physical?
Do you have a Primary Care Physician?
How often do you see your Primary Care Physician?
Text field

Have you had any of the following tests?

Medical Tests


List the medications you are currently prescribed.


Treatment Centers

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

Do you have a Case Manager? Checkboxes
Name of Case Manager: Text field
Contact number for Case Manager: Text field
What is your sobriety date?
Are you currently on Medication Assisted Treatment? 
What type of Medication Assisted Treatment are you prescribed?
Text field
Do you have plans to taper your Medication Assisted Treatment?
When will you begin to taper?
What is your substance(s) of choice? Add multiple by clicking in the box and selecting different options.
Client substances of choice
How many meetings in a week do you attend?
Text field
Do you have a sponsor or recovery coach?
Text field 

Sober Living History

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



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


Living Arrangement

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


Mental Health Information

Tell us briefly about any Mental Health information you might have. 

Have you been clinically diagnosed with a mental health disorder? Dropdown

If yes, what have you been diagnosed with? Text field

Are you in Mental Health Counseling? Dropdown

If yes, how often do you attend Mental Health Counseling? Text field

Criminal History

Please provide us a brief criminal history. 6o3 Sober Living prides itself for working with individuals in the criminal justice system. We, however, cannot accept anyone who has a violant criminal past such as Arson, or sexual offenses and some domestic violance. Please contact us if your criminal history falls into these categories. We will discuss options and make referrals, if needed. 

Do you have any criminal pending charges at this time? Dropdown

If yes, what is your pending charge(s)? Text field

If yes, when is your next court date? Date

Most recent criminal charge? Text field

Are you currently on probation? Dropdown

Referral Source

Who referred you to 6o3 Sober Living? Text field


Thank you for your application. We will be in touch; to let you know we received your application and discuss next steps. If you have any questions, please call us at 603-660-0843.