New Heights, LLC
3980 5th St NE, Columbia Heights, MN 55421
(P) 763-205-2467
Email: newheightssoberhouse@gmail.com
NEW HEIGHTS SOBER HOUSE INTEREST APPLICATION
Personal Information
First Name Client first name Middle Name Client middle name Last Name Client last name
Gender Client gender Birthdate Client birthdate Age Text field
Phone Client phone Email Client email
Where do you currently reside?
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Desired Move-In Date: Date
Estimated Length of Stay: Client estimated length of stay
Criminal Status:
Are you currently involved with the Criminal Justice System?
Checkboxes
Have you been convicted of arson?
Do you have criminal sexual conduct convictions?
Please discuss additional information the staff should be made aware of regarding your recovery?
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Client Signature: Signature Date: Date