Eau Claire Sober Living - Application

Eau Claire Sober Living

Application

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.

NOTE: Our current sober homes serve women but we anticipate opening a men's sober home in the near future. 

 

 

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)

Text field

Referred By:

Text field

What is your current living situation?

Dropdown

Preferred Move in Date:

Date

 

Counselor:

Text field Text field


 

Substances of Choice:

Client substances of choice 

 

RecoveryHistory

 

TreatmentCenterHistory