Application

 

Formerly "Born Again Sober Living" and "New Beginnings Sober Living"

New Beginnings Sanctuary NC Intake Form

A NOTE FROM ADMISSIONS:
PLEASE ENSURE THAT THE PHONE NUMBER YOU PROVIDE ON THIS APPLICATION IS CORRECT AND IN SERVICE SO THAT WE CAN CONTACT YOU IN A TIMELY MANNER.
A PHONE INTERVIEW IS REQUIRED FROM ALL APPLICANTS.

ALL APPLICANTS MUST PASS A URINE SCREENING BEFORE ENTRY AND HAVE A WORKING CELL PHONE AND VALID GOVERNMENT ISSUED ID.

OUR PROGRAM PARTICIPANTS ARE REQUIRED TO ATTEND AT LEAST FOUR (4) OUTSIDE ANONYMOUS MEETINGS A WEEK, OBTAIN AND WORK WITH A SPONSOR, FIND AND OBTAIN EMPLOYMENT, AND PARTICIPATE IN WEEKLY HOUSEHOLD CHORES. 
 
Welcome to the NEW BEGINNINGS SANCTUARY INTAKE WIZARD
 
Click next to begin!

General

Tell us about yourself
What is your first name?
Client first name
 
What is your last name?
Client last name
 
When is your birthdate?
Client birthdate
 
What is your gender identity?
Text field
 
What are your pronouns (if applicable)?
Text field
 
What is your sexual orientation?
Text field
 
What is your transition status (if applicable)?
Text field
 
Comfort Level in LBGTQIA+ Spaces (if applicable)?
Text field
 
Are there any specific concerns or needs you'd like us to be aware of to maintain a safe environment for you?
Paragraph
 

What is your race/ethnicity?
Client race
 
What is your marital status?
Client marital status

Are you employed? If YES - where and how long?
Text field
 

Contact Information

How can we reach you?
Your email address:
Client email
 
Phone Number:
Client phone
 

Contacts

Give us a few people that we can reach out to in case of an emergency.
 
Contact

 

Medical History

Tell us about your medical history.
When was your last relapse date?
RecoveryHistory
 
What is your substance(s) of choice? Add multiple by clicking in the box and selecting different options
Client substances of choice
 
Have you been clinically diagnosed with anything? 
Radio buttons
If yes, please explain: 
Paragraph
 
Do you have any medical health problems? 
Radio buttons
If yes, please explain: 
Paragraph
 
Do you have any medical allergies?
Client allergies
 
 

Medications

List the medications you are currently prescribed.
 
Medication

 

Client Referral Source

 
Who referred you to us?
Text field

Entry and Transportation

 
 
What is the earliest date you wish to enter?
Text field
 

Do you have your own vehicle?

 Radio buttons

Sober Living History

Tell us about any sober livings you've previously been admitted into.
Have you ever lived in a sober living? 
Radio buttons
 
If yes, enter the name: 
Text field
 
 
Is there anything else you want us to know about you?
Text field
 
 
Thank you for applying.
An admission coordinator will contact you shortly, or, you may call (833) 532 - 4440 during regular business hours.
Voicemails will be returned within 24 hours.

For more information, please reach out to jared@nbsnc.org.