New Client Registration Form

1
Do You Want To Stop Drinking Or Using Drugs* This field is required.Please answer honestly as your recovery begins now!
Yes
No
Not Sure
I don't think I have a problem
2
Your Full Name* This field is required.
First Name
Middle Name
Last Name
3
Date of Birth
Month
Day
Year
4
Insurance VerificationPlease enter health insurance information:
Medicaid
Medicare
Commercial
None
Insurance Type
Insurance Provider
Policy/ID Number
Group Number
Insurance Phone Number
5
Address:* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
United States
Please Select
United States
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
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
Country
6
Contact Number:* This field is required.The best number to contact you on
Area Code
Phone Number
7
Work Number:We will never contact your employer without your consent
Area Code
Phone Number
8
Your E-mail* This field is required.Please enter your email address
if you don't have one please enter example@example.com
9
Gender* This field is required.Please enter how you identify
Male
Female
10
Marital Status* This field is required.Please enter your Martial Staus
Single
Married
Divorced
Legally separated
Widowed
11
Emergency Contact:* This field is required.Please add an Emergency Contact if you have one, if not please write 'Not Applicable'
First Name
Last Name
12
Emergency Contact RelationshipPleased add your contacts relationship to you
i.e Mother, Father etc
13
Emergency Contact NumberPlease add your emergency contact number
Area Code
Phone Number
14
What's Your Addiction* This field is required.Please choose from the drop down menu
Alcohol
Drugs (Both street and/or prescribed)
Both
15
Date of Last Drink* This field is required.Please answer honestly, your recovery begins here.
Please enter date of last drink e.g 01/01/2019 or N/A
16
Date of Last Drug Use* This field is required.Please answer honestly, your recovery begins here.
Please enter date of last drug use e.g 01/01/2019 or N/A
17
List of Drugs Used & Frequency* This field is required.Please add ALL drugs used, the amount and how often or N/A if no drugs used
18
Are You Part of a 12 Step Program* This field is required.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.
i.e Love 12 step, never attended, don't like it etc.
19
If Any, How Many Meetings Do You Attend Each Week?* This field is required.Please answer honestly so that we may help you in the very best way
1 - 3
3 - 5
6 or more
No meetings
20
Are You Employed* This field is required.Please select one option from below
Yes
No
Looking for work
On Disability
21
If you do not have a job, will you get one? If yes, what job plans do you have?* This field is required.Please answer in detail below what your plans are
22
Are you getting welfare or other non-job related income?* This field is required.Please select one option below
Yes
No
23
What is your monthly income?* This field is required.Please tell us your monthly income from work or welfare
i.e $3000.00
24
What do you expect your monthly income to be next month?* This field is required.Please tell us your next months income from work or welfare
i.e $3000.00
25
Do you have a medical doctor?* This field is required.Please select one option
Yes
No
26
Have you ever been in a treatment facility for alcoholism and/or drug addiction?* This field is required.Please select one option
Yes
No
27
If You Are In Treatment or In Recovery Please Give Details Below* This field is required.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.
28
Do you take prescription drugs? If yes, please list it here* This field is required.Please list all medications (DRUG NAME, DOSE, FREQUENCY, ROUTE) that you are currently prescribed, if more than one, separate them with a comma.
Huge
Large
Normal
Small
Ok
Ok
29
Date You Wish To Move In* This field is required.If not immediately why not? e.g. Finishing treatment in 7 days or Saving Up Money etc.
i.e. Immediately, 01/01/2019 or Thursday 7th August as I leave treatment on that day
30
Have you ever lived in an LIV Recovery Sober Living Home? If yes, provide the name and location of the home* This field is required.Please give as much detail as possible or write N/A
31
If you answered yes please tell us why you left the LIV Recovery Sober Living home:* This field is required.Please give as much detail as possible or write N/A
i.e. Relapse, Voluntary or other reason
32
Did you owe money to the LIV Recovery Sober Living Home you left?* This field is required.Please answer honestly below
Yes
No
N/A
33
If you did owe money, do you agree to repay the money owed to your former LIV Recovery Sober Living Home* This field is required.Please answer honestly below
Yes
No
N/A
34
Use This Space To Add Any More Relevant Information You Think We May Need To Know
35
Use This Section To Tell Us About Any Criminal/Legal IssuesPlease 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.
36
I have read all of the material on this application form including the limitations set forth below. I have also answered each question honestly and want to achieve comfortable recovery from alcoholism and/or drug addiction without relapse.* This field is required.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.
Clear
Should be Empty: