Eudaimonia Sober Living and Extended Care

Program Application


This application is for internal uses only. The questions are designed to assist Eudaimonia Recovery Homes in utilizing our resources to assist you in your recovery through accountability and aiding you in any obstacles you may need to overcome.

Demographic Information:

Full Name:   

Date of Birth:   

Social Security Number:   

Home Address:   

City:   State:   Zip:   

Phone Number:   Email:   

Martial Status :  

 

Emergency Contact

Full Name:   

Phone Number:   

Email Address:   

Relationship:   

Legal

Are you currently on probation or have pending charges? (Please provide detailed information):   

Have you ever been convicted of any felonies?:

 

Treatment History

Sobriety Date: 

Are you discharging from a substance abuse facility: 

 

If Yes: Treatment Center:

Counselor Name: 

Counselor Email: 

Counselor Phone Number:   

Discharge Date: 

Current Medications: 

 

Aftercare

Will you be bringing a vehicle? 

 

Are you currently employed, and plan to remain with your employer during our program?: 

 

Are you currently enrolled in school, and plan on continuing as a full-time student?: 

 

Will you be attending an Intensive Outpatient Program (IOP)?: 

 

If Yes: Name of IOP provider:  

If no, would you like information regarding our IOP program?: 

 

Location

Which city are you interested in?: 

 

Is there a particular home you are wanting to live in?:   

Have you lived in a sober living home before?: 

 

How did you hear about Eudaimonia Recovery Homes?:   

Financials

Yearly Gross Income:   

Yearly Expenses:   

Are you wanting to : 

 

If Utilizing Insurance:

Insurance Company:  

Company Phone Number:   

Member ID Number:   

Group Number:   

Type of Plan:   

 


 

By signing the application below, I authorize Eudaimonia Recovery Homes to utilize the above information to process my request for membership. By providing my insurance information, I am authorizing Eudaimonia Recovery Homes to perform a verification of my out of network benefits. I also attest the information I am providing is accurate. I also understand, that a completed application, is not guarantee of admissions into our program.

 

 

 

 

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Eudaimonia Sober Living and Extended Care http://www.eudaimoniahomes.com
Signature Certificate
Document name: Program Application
Unique Document ID: d0cc967a971686823010398b0949002181f75b3d
Timestamp Audit
2015-10-10 21:35:55 CDTProgram Application Uploaded by Mat Gorman Gorman - mat@novarecoverycenter.com IP 64.234.21.82