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UNITY SOBER LIVING NEW INTAKE FORM
Unity Sober Living Homes may utilize the information in rendering a decision on my acceptance into the program. Any act of dishonesty, or failure to disclose any pertinent information can and will lead to discharge from the program. 
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Email *
First & Last Name *
Phone *
Date of Birth *
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Gender *
Drug of choice? *
MAT (Medication assisted treatment)? *
If yes to the above question please specify below
Please list all prescription medications  *
Medical Insurance *
Insurance Provider  *
Registered sex offender *
Are you currently employed? *
Able and willing to work? *
Active/Outstanding Warrants? *
Parole /Probation  *
Emergency Contact Name and Phone Number *
Emergency Contact Relationship to Client *
Are you currently in treatment? *
If yes, when will you discharge?
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Referral Source Name & Best Contact Number *
Referral Source Company Name *
Referral Source Contact Email *
I hereby certify that the information above is true and accurate. Unity Sober Living Homes may utilize the information in rendering a decision on my acceptance into the program. Any act of dishonesty, or failure to disclose any pertinent information can and will lead to discharge from the program.  *
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