Application

Application Packet PDF

Print the Application Packet above or fill out the electronic version below. 

General Information
Resident Name *
Resident Name
Phone *
Phone
Date of Birth
Date of Birth
Family Information
Emergency Contact Name
Emergency Contact Name
Emergency Contact Phone Number
Emergency Contact Phone Number
List of medications you are currently takings
History of drug use
Briefly describe your history of drug or alcohol use. When did you start using? What did your use lead you to? In the end, did you continue using the same substance or did you graduate to others? What has brought you to this point?
Insurance information
While staying at the Fourth Dimension Sobriety House circumstances may lead to residents to seek medical, therapeutic and other services. Furthermore, Fourth Dimension Sobriety reserves the right to drug test residents. All Tests that are sent to labs for testing (2-3 times a week) will be billed to the resident's insurance. Therefore, we ask that you please provide your insurance information so we can assist in the process of our residents obtaining outside medical or psychiatric help upon request.
Permanent Address
Permanent Address