Serenity Bridge Sober Living
Freedom to choose how you recover
Sober Living Application
Rules and Guidelines
Phase System
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Name
*
First
Last
Gender
-Select-
-Select-
Male
Female
Address
Date of Birth
*
Phone Number
Email
Marital Status
-Select-
-Select-
Single
Married
Divorced
Seperated
Engaged
Widowed
Current Living Situation
-Select-
-Select-
Personal Residence
Live with Family
Treatment
Incarcerated
Homeless
Emergency Contact Info
Are you required to register as a sex offender?
*
-Select-
-Select-
Yes
No
Do you have any active warrants?
select
select
Yes
No
List Criminal History
if none please put N/A
Drug of Choice
*
Meth
Fentanyl
Alcohol
Heroin
Marijuana
Sobriety Date
Are you in a 12 Step Program?
If yes please specify.
If you're currently in treatment, jail or halfway house, when is your release date?
Treatment Provider or Halfway House Info:
Please input Name, Address, Phone number, Case Workers Name
What are some short term goals you have?
*
Probation officer's Name and Number:
Do you give us permission to contact the treatment center, halfway house or probation officer?
*
-Select-
-Select-
Yes
No
By selecting No, your application may be delayed if you have a PO.
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