Date: Date

Client Contact Information 

Name Client first name Client last name

Home Address: Client Address

City: Client City State: Client State Zip: Client Zip

Primary Phone: Client phone

Home Phone: Text field

Work Phone: Text field

Email Address:Client email

Please indicate the best way and time to contact you Text field

DOB: Client birthdate

Current Location Text field

If this is a Treatment Center, Halfway House, Jail, or other Institution, how long at this location? Text field

Discharge Date or anticipated Discharge Date Text field

What is your Drug of Choice? Text field

Do you have ANY other addictions/dependencies/disorders? Text field

Place of employment:

Employer: Employer 1 name Position: Employment 1 position

Work Phone: Text field

How did you hear about Trinity Sober Living?

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Other Text field

Are you currently on Probation or Parole?

Radio buttons

If YES, where? Text field

What is your PO's name and contact information? Text field

Are you required to register as a sex offender?

Radio buttons

If "Yes", where and when was your adjudication date?  Text field

Do you have any felonies?

Radio buttons

If so, list them below with conviction date and time in days, months, or years that you were incarcerated, if any:

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What is your longest period of continuous sobriety? Text field When (What Year(s))? Text field

In a sentence or two, tell us why you want to join Trinity House and why you believe you would be a good fit for our Sober Living Home.

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Trinity Sober Living Homes ranges in cost from $400/week - $700/week at the Men's Home in Bensenville. This cost does not include food. ALL fees must be paid four weeks in advance for the next four weeks in order to remain a resident in good standing.

Thank you for considering Trinity Sober Living as a part of your journey toward long term sobriety and an important step toward extraordinary recovery. A member of our staff will be in touch with you within the next 48 hours to discuss the next step toward becoming a resident in our Sober Living Home.