Temperance Sober Living Application Please enable JavaScript in your browser to complete this form.Name *FirstLastDate of Birth *Phone *Sobriety Date *Email *Current or preferred recovery program? *Most recent treatment facility? *When were you in treatment last (if applicable)?Drug(s) of choice? *Are you Employed?YesNoIf unemployed, when do you expect to be employed?If you have a vehicle, do you have a current driver’s license and valid insurance?Are you on probation? *YesNoMost recent conviction (if applicable)?Please provide a brief description of any conviction(s) past or pendingDo you have any convictions for Arson or Sex Offenses: *YesNoAny history of self-harm or suicide attempts? *YesNoAny current or past mental health diagnosis? *YesNoPlease provide a brief description of current or past health diagnosis (if applicable):Have you been in other sober livings? *YesNoWhich sober living(s) have you been in previously (if applicable):Why did you leave sober living (if applicable)?How do you plan on paying program fees? *Have you had a scholarship at another sober living? *YesNoMost recent scholarship (if applicable)Is there anything else you would like us to know?Submit