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ARTS Women’s Sober Living Home – Interest Form
"
*
" indicates required fields
Section 1: Self or Referral
Question: Are you filling this out for yourself or referring someone else?
For myself
Referring someone else
Note: ARTS Sober Living Home provides housing and community support for women in recovery. This is not a treatment program or medical provider.
Name of the person being referred
Phone number of person being referred
Email of person being referred
Your Name
First
Your Phone Number
Relationship to the person being referred:
Friend or Family
Peer / Sponsor / Support Group Member
Community Organization Contact
Other
Other
Section 2: Personal Information
First Name
*
Last Name
*
Name you go by
Date of Birth
*
MM slash DD slash YYYY
Phone Number
*
Email Address
*
Section 3: Sober Living Questions
Are you interested in living at ARTS Women’s Sober Living Home?
*
Yes
No
Are you 18 or older?
Yes
No
Are you currently maintaining sobriety?
Yes
No
How long have you been maintaining sobriety?
Less than 1 month
1–3 months
4–6 months
7–12 months
Over 1 year
Do you have children who would live with you? (We can accommodate up to 2 children under age 5.)
Yes
No
Children’s ages
Under 1
1
2
3
4
Are you pregnant?
Yes
No
Due date
MM slash DD slash YYYY
When would you like to move in?
MM slash DD slash YYYY
How did you hear about us?
Δ
ARTS TREATMENT PROGRAM DIRECTORY
Phone:303-336-1600
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