Intake form | Sober Maintenance

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Full Name

Date of Birth*

Age*

Phone*

Email*

Emergency Contact

Date of Intake*

Living Situation*

Alone

With Family

With Partner

Sober Living

Transitional Housing

Unstable Housing / Homeless

Other

Prefer not to say

Employment Status*

Employed Full-Time

Part-Time

Unemployed

On Disability / EI

Student

Retired

Prefer not to say

Legal Issues*

Yes

No

Prefer not to say

Details of Legal Issues (if any)

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