Questionnaire

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Membership Questionnaire

Not sure where to begin with Sober at Home? Fill out the questionnaire below to see what program is right for you. Answer each question honestly and thoughtfully so we can help guide you on your road to recovery.

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.

There is no better time to start than right now!

First Name*
Last Name
Age
Phone*
Email*
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 the 12 steps
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?
Questions or Comments
Comments
This field is for validation purposes and should be left unchanged.

Questionnaire

Membership Questionnaire

If yes, please answer the following question

If yes, please fill in the following emergency contact details

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