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Help us get to know you.
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Name
First
Last
Phone Number
Email Address
*
Not entering your name, phone number and email address may delay the assessment process.
Date of Birth
What are you suffering from (Select all that apply)?
Alcoholism
Drug Addiction
Other
When was the last time you drank or used drugs?
Have you ever attended AA or NA meetings?
Yes
No
When bring income?
List any doctor prescribed medications you are currently taking
Do you have any medical issues?
Please describe any legal issues (parole, probation, warrants)
Are you a registered sex offender?
Yes
No
Do you have a source of income?
Yes
No
Are you physically able to work?
Yes
No
Do you have a state issued ID (Driver's License, ID Card, Passport?)
Will you bring a vehicle with you?
Yes
No
Are you willing to give up your personal electronics for a period of time?
Yes
No
Why are you wanting to try My Brother's House?
What do you expect to gain from your recovery at My Brother’s House?
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