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
May we contact your HR Department or Supervisor?
If YES, are there any restrictions or information that we need to know about prior to speaking with them? Text field
Contact Information of Supervisor or HR Dept (name, phone, email address):
Are you currently on Probation or Parole?
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?
If "Yes", where and when was your adjudication date? Text field
Do you have any felonies?
If so, list them below with conviction date and time in days, months, or years that you were incarcerated, if any:
What is your longest period of continuous sobriety? Text field When? Text field
In a sentence or two, tell us why you want to join Trinity House and why you believe you would be agood fit for our Sober Living Home.Paragraph
Trinity Sober Living Homes ranges in cost from $400/week - $800/week (depending on facility). This costdoes not include food. ALL fees must be paid four weeks in advance for the next four weeks in order toremain a resident in good standing.
Thank you for considering Trinity Sober Living as a part of your journey toward long term sobriety andan important step toward extraordinary recovery. A member of our staff will be in touch with you withinthe next 48 hours to discuss the next step toward becoming a resident in our Sober Living Home.