This application is for internal uses only. The questions are designed to assist Eudaimonia Recovery Homes in utilizing our resources to assist you in your recovery through accountability and aiding you in any obstacles you may need to overcome.
Date of Birth:
Social Security Number:
Home Address: City: State: Zip:
Martial Status : SingleMarriedDivorced
Full Name: Phone Number: Email Address: Relationship:
Are you currently on probation or have pending charges? (Please provide detailed information): Please provide the charge and current court date
Have you ever been convicted of any felonies?: Please enter the charge and date
Sobriety Date: Are you discharging from a substance abuse facility:YesNo If Yes: Treatment Center:
Counselor Name: Counselor Email: Counselor Phone Number:
Discharge Date: Current Medications: Please list the name, dose and frequency of the prescribed medication
Will you be bringing a vehicle? YesNo Are you currently employed, and plan to remain with your employer during our program?: YesNo Are you currently enrolled in school, and plan on continuing as a full-time student?: YesNo Will you be attending an Intensive Outpatient Program (IOP)?: YesNo If Yes: If no, would you like information regarding our IOP program?: YesNo
Which city are you interested in?: Austin, TXHouston, TXColorado Springs, COChicago, IL Is there a particular home you are wanting to live in?: Have you lived in a sober living home before?: YesNo How did you hear about Eudaimonia Recovery Homes?:
Yearly Gross Income: Yearly Expenses: Are you wanting to : Private PayUtilize Insurance
If Utilizing Insurance: Insurance Company: Company Phone Number: Member ID Number: Group Number: Type of Plan:
Call us now and begin healing at (512) 363-5914 or you can fill out form below and we will contact you shortly.
Or text us and we will call you right back.
Which city are you interested in? Austin, TXHouston, TXColorado Springs, CO
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