House Applied For
Ohana - Women's Sober Living
Mahalo- Men's Sober Living
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What is the date (or upcoming date) of your last discharge?
Are you currently on probation/parole/house arrest?
Yes
No
Are you currently in any other treatment services?
Yes
No
Married
Single
Do you have children?
Yes
No
Does addiction run in your family?
Yes
No
Do any of your family members participate in support groups such as Al-Anon/Teen?
Yes
No
Personal References
I understand that the information given is accurate and true. Also I give consent to contact any persons whose names are provided to gain information regarding my application.
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