Email

Please leave your email if you have one

How did you hear about us?

Will you be in an outpatient program or other services?

Will you be in an outpatient like Nuway or another program while living at the house? (Please List the Treatment)

Where are you staying currently?

Where are you currently living? e.g. treatment, another sober living. with a friend etc.

Gender Identity and Preferred Pronouns

What gender do you identify as? Preferred Pronouns

Sexuality (optional)

Sexuality

Medications

Please list which medications you are currently prescribed

Do you use medicinal Cannabis?

Or within the past 30 days?

Hospital Stays

Have you been hospitalized for mental health in the last two years? If so please explain the circumstances.

Best time to call you

When is the best time to give you a call back?

Any other info?

Is there anything else you would like us to know about you?