Please complete the application below, so that we might have a better idea of how best to serve you and to prepare for your stay.
Name:
Client first name Client last name
Gender:
Client gender
Date of Birth:
Client birthdate
Current Phone:
Client phone
Primary Email:
Client email
County of Residence
Text field
Tribal Affiliation (if applicable)
Have you served in the Military?Text field
Referred By:
What is your current living situation?
Dropdown
Preferred Move in Date:
Date
Please list the names and ages of your children
Paragraph
Are you on the sex offender registry?
Do you have any charges for violence?
if yes explain.
Due to our commitment to resident safety and well-being, Eau Claire SoberLiving does not accept applicants who are registered sex offenders or havea history of felony violent criminal behavior. Applications will also bedenied if false or misleading information is provided during the screeningprocess.
Counselor:
Substances of Choice:
Client substances of choice
RecoveryHistory
TreatmentCenterHistory