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LIV Recovery Sober Living

LIV Recovery Sober Living

To be accepted in an LIV Recovery Sober Living Home, an applicant must complete this application and be interviewed.
37Questions

HIPAA

Compliance

  • 1
    Please answer honestly as your recovery begins now!
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  • 2
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  • 3
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    Pick a Date
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  • 4
    Please enter health insurance information:
    • Medicaid
    • Medicare
    • Commercial
    • None
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  • 5
    United States
    • Please Select
    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curaçao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • United States
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
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  • 6
    The best number to contact you on
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  • 7
    We will never contact your employer without your consent
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  • 8
    Please enter your email address
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  • 9
    Please enter how you identify
    Please Select
    • Please Select
    • Male
    • Female
    • Nonbinary
    • Rather not answer
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  • 10
    Please enter your Martial Staus
    Please Select
    • Please Select
    • Single
    • Married
    • Divorced
    • Legally separated
    • Widowed
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  • 11
    Please add an Emergency Contact if you have one, if not please write 'Not Applicable'
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  • 12
    Pleased add your contacts relationship to you
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  • 13
    Please add your emergency contact number
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  • 14
    Please choose from the drop down menu
    • Alcohol
    • Drugs (Both street and/or prescribed)
    • Both
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  • 15
    Please answer honestly, your recovery begins here.
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  • 16
    Please answer honestly, your recovery begins here.
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  • 17
    Please add ALL drugs used, the amount and how often or N/A if no drugs used
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  • 18
    Please tell us if you attend 12 step, or if you have ever attended 12 step, if it is a good fit for you or if you don't like it and why. There are no right or wrong answers, only honest ones.
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  • 19
    Please answer honestly so that we may help you in the very best way
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  • 20
    Please select one option from below
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  • 21
    Please answer in detail below what your plans are
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  • 22
    Please select one option below
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  • 23
    Please tell us your monthly income from work or welfare
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  • 24
    Please tell us your next months income from work or welfare
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  • 25
    Please select one option
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  • 26
    Please select one option
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  • 27
    What is your current recovery program if any. If you are in treatment the treatment facility name and contact details. Also If in treatment what is your successful completion date from treatment.
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  • 28
    Please list all medications (DRUG NAME, DOSE, FREQUENCY, ROUTE) that you are currently prescribed, if more than one, separate them with a comma.
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  • 29
    If not immediately why not? e.g. Finishing treatment in 7 days or Saving Up Money etc.
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  • 30
    Please give as much detail as possible or write N/A
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  • 31
    Please give as much detail as possible or write N/A
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  • 32
    Please answer honestly below
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  • 33
    Please answer honestly below
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  • 34
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  • 35
    Please be as honest and detailed as possible including Are you aware of any current active warrants. Are you currently in the legal system & Are you on probation or parole.
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  • 36
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  • 37
    I realize that the LIV Recovery Sober Living Home to which I am applying for residency has been established in compliance with the conditions of § 2036 of the Federal Anti-Drug Abuse act of 1988, P.L. 100-690, as amended, which provides that, federal money loaned to start the house requires the house residents to (A) prohibit all residents from using any alcohol or illegal drugs, (B) expel any resident who violates such prohibition, (C) equally share of household expenses, including the monthly lease payment, among all residents, and (D) utilize democratic decision making within the group including inclusion in and expulsion from the group. In accepting these terms, the applicant excludes himself or herself from the normal due process afforded by local landlord-tenant laws.
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