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Membership Questionnaire

START YOUR JOURNEY TO RECOVERY HERE!

We believe that every individual is capable of living a life free from addiction. We have the knowledge, the experience and the tools to help you find that freedom, regardless of your past experience with traditional addiction treatment.

Let us help you best by taking the questionnaire below. Answer each question honestly and thoughtfully so we can help you.

There is no better time to start than right now!

First Name
Last Name
Age
Phone*
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Level of Care: If you feel your substance use requires inpatient care, please contact your local resources for assistance and return to Sober at Home, Inc. for ongoing support once you have completed your inpatient stay.
Drug of Choice
Others
How do you use your substance?
Others
When was the last time you used your drug of choice
Other
Frequency of Use
Please provide further details on your frequency of use.*
Substance Use Treatment History: How many treatment episodes have you had?
Substance Abuse Treatment Type: (Select Most Recent)
Substance Abuse Treatment State
Substance Use Treatment History Outcome
Are you currently on Medication Assisted Therapy?
If you are prescribed Medication Assisted Therapy, Which type?
Other
Have you been diagnosed with a mental health condition?
If yes, please answer the following question
Diagnosis
Other
Do you work?
Describe your experience with 12 step
In case of emergency, do we have permission to contact someone?
If yes, please fill in the following emergency contact details
First Name
Last Name
Phone*
Relationship
Please select the appropriate option

Have you been sober for 30 days or less?

Have you have been sober for greater than 30 days but less than 60 days?

Have you have been sober for greater than 60 days but less than 6 months?

Have you been sober for greater than 6 months?
Congratulations! You are one step closer to getting sober and knowing that you don't have to do it alone. Based on your responses the program that would best fit your needs is:
Phase 1
Phase 1 or Phase 2
Phase 2 or Phase 3
Phase 3
See below to go to our group schedule to select days and times that fit your schedule. You can always try out Sober at Home services by joining our Introductory Open Group package.
Questions or Comments
Phone
This field is for validation purposes and should be left unchanged.

Group Calendar

My Story

Eileen Hackett

RN

David is creative in his techniques and style in reaching those struggling with addiction. He truly is passionate and believes that all are capable of living a life of sobriety. He is the best man to help you through the process.

Liz Harris

RN

David Gerber is a man with great respect, integrity & many years of understanding and knowledge in this field. I am proud to call him a freind. This is a venture I would recommend to someone who is in need of help and/or guidance and information.

Christopher G.

Alumnus

David has impacted my life in such a positive manner. I learned so much from David and his team. He truly is a man who loves what he does. I did not love myself before I met him, but now I know I am a man worthy of love and respect.

Susan Salamone

Drug Crisis in our Backyard

David Gerber is an expert in the field of substance use disorders and truly understands how to help someone who is struggling with addiction.

Questionnaire

Membership Questionnaire

START YOUR JOURNEY TO RECOVERY HERE!

If yes, please answer the following question

If yes, please fill in the following emergency contact details

My Story

Eileen Hackett

Liz Harris

Christopher G.

Susan Salamone

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