Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Prior Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Emergency Contact *

First Name

Last Name

Phone *

(###)

###

####

Are you currently Employed *

Yes

No

Are you able or do you have assistance to afford the program fees associated with Luv Care? *

Yes

No

Do you believe that you need detoxification: *

Yes

No

Are you currently in treatment for substance use (Therapy, PHP, IOP)? *

Yes

No

What is your Sobriety Date? *

MM

DD

YYYY

Do you have a sponsor *

Yes

No

Are you open to or currently working a 12-Step Program? *

Yes

No

Are you currently on MAT? *

Yes

No

Do you agree to store your medications according to our medication storage policy and procedure during your stay with us? *

Yes

No

Do you agree to not disclose your medications to other residents? *

Yes

No

Have you traveled out of the country in the last 30 days? *

Yes

No

Have you come in contact with anyone with an infectious disease? *

Yes

No

Do you currently have any covid symptoms? *

Yes

No

Any history of causing harm to yourself or another? *

Yes

No

Are you court-ordered to sober living or on probation? *

Yes

No

Are you a registered sex offender? *

Yes

No

Are you on community control? *

Yes

No

Are you on house arrest? *

Yes

No