Sober Living Application NJ | Ocean County Sober Living

Step 1 of 7

About You

First name *

Last name *

Date of birth *

Gender *

Phone *

Email

Street address

City

State

ZIP code

Are you a veteran?

Step 2 of 7

Treatment and Move-In

Are you currently in treatment? *

If yes, what level of care?

Are you set up with aftercare (IOP, OP, therapy)?

Do you need a referral to a treatment program?

Desired move-in date *

Room preference

Any concerns with sharing a room?

Are you able to do household chores?

Step 3 of 7

Payment and Insurance

Shared room: $225 per week. Move-in fee: $550, includes your first week of rent (non-refundable).

How will you pay rent?

Myself, from work income Myself, from savings Family Other

If someone else is paying, who?

Their phone

Health insurance provider

Policy holder name

Step 4 of 7

Emergency Contacts

Emergency contact 1 name *

Relationship *

Phone *

Emergency contact 2 name

Relationship

Phone

Step 5 of 7

Recovery and Health

Step 6 of 7

History

Treatment centers you attended (name and year)

Sober livings you lived in before (name and dates)

Employment status

Employer

Where are you living now?

Transportation

Step 7 of 7

Final Step

How did you hear about us?

Anything else we should know?

The information I provided is true and complete. * I agree to be contacted by Ocean County Sober Living by phone, text or email. *