Resident Application - Redemption 369

Full Name

First

Last

Date of Birth

Phone Number

Is this information for yourself, a family member, or friend?

Address (Street, City, State, Zip, County)

Do you have an alcohol problem?

Do you have a drug problem?

Do you want to stop drinking/using?

How many recovery meetings do you attend per week?

Currently in treatment or facility?

If yes, please put information on the treatement / facility

Treatment / Facility Details (skip if not applicable)

Do of as

Employment Status

Do you receive any additional sources of income (such as retirement, disability, family support, welfare, etc.)?

If yes, please specify the type.

Medical Doctor (Name + Phone Number)

Mental Health Professional (Name + Phone Number)

Medications (List name, dosage, mg)

Name of last treatment center/detox (If never, enter N/A)

Number of times in treatment/detox (If none, enter N/A)

Have you previously lived in a sober living house?

Desired Move-in Date

3 Emergency Contacts (Name, Relationship, Phone Number)

Please share any relevant information related to your recovery, including why you want to live here.

FREQUENTLY ASKED QUESTION

Common questions about our rehab services

What is physiotherapy?

We provide comprehensive treatment for wide range of addictions, including alcohol, prescription medications, opioids, heroin, cocaine, methamphetamine, and other substances.

Do you offer personalized treatment plans?

We provide comprehensive treatment for wide range of addictions, including alcohol, prescription medications, opioids, heroin, cocaine, methamphetamine, and other substances.

How do I know if I need rehab?

We provide comprehensive treatment for wide range of addictions, including alcohol, prescription medications, opioids, heroin, cocaine, methamphetamine, and other substances.

What kinds of programs do you offer?

We provide comprehensive treatment for wide range of addictions, including alcohol, prescription medications, opioids, heroin, cocaine, methamphetamine, and other substances.

FREQUENTLY ASKED QUESTION

Common questions about our rehab services

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