NICK'S HOUSE QUESTIONNAIRE
*This information is confidential and will not be shared*
What is your First & Last Name? *
Your answer
What is your email (If you have one)?
Your answer
What is your phone number, or good contact number? *
Your answer
What is your addiction/drug of choice? *
Your answer
How long have you been clean? *
Your answer
Did you complete rehab? *
If yes, when, where and what is a good contact name and number for the center? *
Your answer
Do you have a sponsor? *
If yes, what is their name and contact number? *
Your answer
Are you working the steps? *
Are you attending meetings? *
Do you have a home group? *
Are you currently working? *
If yes, where?
Your answer
What shift and hours?
Your answer
Are you currently taking any prescribed or over the counter medication? *
If yes, what are you taking?
Your answer
What is your mode of transportation? *
Your answer
Who will be paying your rent? *
Your answer
Are you able to pay $150/week? *
Is there anything else we should know?
Your answer
House rules- check each one stating you read and understand. *
Required
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