Program Application

    Program Application

    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.

    Demographic Information:

    Full Name:

    Date of Birth:

    Social Security Number:

    Home Address:
    City:
    State:
    Zip:

    Phone Number:

    Email:

    Martial Status : SingleMarriedDivorced

    Emergency Contact

    Full Name:
    Phone Number:
    Email Address:
    Relationship:

    Legal

    Are you currently on probation or have pending charges? (Please provide detailed information):

    Have you ever been convicted of any felonies?:

    Treatment History

    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:

    Aftercare

    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

    Location

    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?:

    Financials

    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:

    Signature:

    Take Action Today

    We Are Ready to Assist You

    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.

      Your first name (required)

      Your last name (required)
      Your Email (required)

      Phone Number (required)

      Your Message

      Which city are you interested in?
      Austin, TXHouston, TXColorado Springs, CO

      What Makes Us Different

      • Why Choose Eudaimonia for Your Sober Living Experience?
      • Recovery-Focused Lifestyle
      • Individualized Care
      • Homes for Everyone
      • On-Site Support Staff
      • Family Support
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