Apply Online | Time 2 Rise Above

Your Name *

Phone *

Email Address *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Date of Birth *

Date of Birth

Age *

Do you have a driver's license or other form of ID? *YesNo

Emergency Contact *

Phone *

Insurance Coverage *

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Primary Care Provider Name *

Phone *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Current Medications *

Are you on probation? *YesNo

Are you in Drug Court? *YesNo

Probation Officer Name

Phone

Are you coming from a treatment center? *YesNo

Did you complete/graduate? *YesNoN/A

How long have you been abstinent from drugs and alcohol? *

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Sobriety date: *

Do you have a vehicle that will be parked at the house? *YesNo

Make

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Model

0 / 25

Current Employer *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

How long have you been there? *

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Position: *

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Seasonal/Full-Time/Part-Time: *

0 / 25

Have you ever been sober before? *YesNo

For how long? *

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Is anyone in your life still actively using? *YesNo

Do you have a sponsor? *YesNo

Do you have a recovery home group? *YesNo

What do you see as your biggest obstacles to maintaining sobriety? *

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What are your goals while with us at Rise Above? *

0 / 500

Who are your biggest supporters at this time? *

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Are there any special situations or circumstances you would like to share with us? *

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I have read the Rules and Guidelines and agree to abide by them: *

Today's Date: *