Lodger Application

Serenity House of Green Bay, LLC

1254 & 1357 Cherry Street

Green Bay, WI

54301

(920) 489-2412

SerenityHouseGB@gmail.com

 

 

Initials Text field  Please initial here signifying you have read and understand all of Serenity House of Green Bay, LLC current policies and procedures along with the phasing systems in place

General Details:

First Name:    Client first name

Last Name:    Client last name

Birthdate:      Client birthdate

Sex:     Client gender

Phone Number:  Client phone

Email Address:  Client email

 

 

Client allergies

Medication

RecoveryHistory

Client substances of choice

 

TreatmentCenterHistory

Counseling History

Therapist/Clinician

Criminal History

Probation

 

Emergency:

Emergency Contact:

Contact

 

Other:

Is there anything else you wold like to share?

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Signature:

Signature

Date:  Date