Apply | Sober Living Center | Providence Retreat, Hollis, Maine

Legal Name *

First

Last *

Last

Date of Birth *

Email *

Phone *

Current Address *

City *

State *

Zip *

Date of Last Use *

Drug of Choice *

How do you intend to initially afford sober living? *

Do you have any current legal issues? *

No

Yes

If so, please explain the issues.

Do you have a criminal record? *

No

Yes

If yes, please list the charges.

Are you required to register as a sex offender? *

No

Yes

Do you have any current medical conditions? *

No

Yes

If so, please explain the conditions.

List all current medication (prescription and over-the-counter).

Are you currently in detox? *

No

Yes

If so, where?

Expected date of entrance? *

Have you been in treatment in the past for alcohol/drug addiction? *

No

Yes

If so, where?

Do you have any allergies? *

No

Yes

If so, please describe allergies.

Emergency contact information *

Contact’s Name

Emergency contact information *

Contact’s Phone

Emergency contact information

Contact’s Address

Where did you hear about Providence Retreat? *

Internet

Detox Referral

Past Guest

Other

Specify

Explain what made you decide to ask for help and what you are hoping to get out of your experience at Providence Retreat. *

I am willing to commit to 28 days to complete the program. *

Agree

I will communicate any changes to the information that is provided in this application *

Agree