All potential residents must fill out this form and submit it. Submitting this application is not a guarantee of admission.
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First Name *
Middle Name
Last Name *
Street Address 1 *
Street Address 2
City *
State *
Zip Code *
Age *
Email Address *
Your Phone Number (cell)
Emergency Contact Name *
Emergency Contact Phone *
Emergency Contact Relationship\ *
Drug & Alcohol History *
Date of Last Use *
If you are in treatment now, what is the name of the treatment facility?
Name of Counselor
Counselor's Phone or Email Address
Expected Discharge Date
Are you scheduled to attend PHP or IOP *
If you are scheduled for PHP or IOP, where?
Previous Treatment Centers
Previous Sober Living/Recovery House Arrangements
Check Any / All That Apply *
If you checked any of the above, please explain in more detail
Do you have medical insurance *
Insurance Provider
If you take prescription medication(s), list medications
Allergies & Medical Conditions
Allergies and Medical Conditions (Please list anything you are allergic to along with what happens if you are exposed to it (e.g. Peanuts - break out in hives) as well as any medical conditions you may have (Bipolar Disorder, Carpal Tunnel Syndrome, etc) putting each allergy/condition on a separate line. If you do not have any allergies or medical conditions apart from your addiction, put "none")
Are you currently employed *
If not, are you able to work
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If you are unable to work, please explain why
Employer's Name
Supervisor's Name
How Many Hours Do You Work a Week?
Work Schedule
I agree to these Terms and Conditions - By selecting the checkbox below and typing my name, I hereby certify that the information above is true and accurate and that "BridgeWay House" may utilize the information I provided in rendering a decision on my acceptance into the sober living program they facilitate as well as to run a background check and schedule a pre-acceptance interview with me. *
Please Write Out Your Full Name - By writing your full name, you accept and agree to the above statement. *
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