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
Have you ever been known by an alternate name?
When is your birthdate?
What is your race/ethnicity?
What is your gender identity?
What is your marital status?
Client marital status
Are you a veteran?
Social Security Number:
Driver's License or State Issued Identification Number or other Identification Card Number:
Who is completing this application?
How can we reach you?
What is your email address?
At what phone number can we best reach you at?
Do you consent to a background check?
I agree to be contacted by Starts With Love Foundation-Saguaro House via SMS, email, or phone using the information I provided for the purposes of reviewing my application.
Tell us about your medical history.
When was your last relapse date?
Recovery history 1 relapse date
What is your substance(s) of choice?
Client substances of choice
Have you been clinically diagnosed with anything?
Do you have any health problems?
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.
Have you had any of the following tests?
Do you have any issues ascending or descending stairs?
All residents are required to seek employment, be enrolled in school at least part-time, or take part in volunteer work up to 32 hours per week.
What are you plans?
How will you pay for the program? Apple Pay, Zelle, and Cash are accepted.