serenitynowdelray.com - Information Request Form

Last Name:

First Name:

Middle Initial:

E-Mail Address:

Last Address:

Apartment:

Town/City:

State:

Zip Code:

Phone #:

Cell/pager:

Other #:

Drivers License #:

License Plate #:

Current Vehicle (Make/Model):

Information Request Form

NAME AND CONTACT INFORMATION

Get started today on your path to recovery by applying to Serenity Now. Simply complete this online application form, being careful to provide answers to all of the questions on this and the following page. Please be sure to review the Expectations and Rental information prior to applying. All information submitted will be kept strictly confidential.

PERSONAL RECOVERY INFORMATION -- Page 2

Have you been to any Rehab Facilities?

If yes, please give the facility name, address, and contact:

Reasons for leaving:

Have you been to any Sober Living Facilities?

If yes, please give facility name, address and contact:

Reasons for leaving:

Are you currently employed?

If yes, state employer, address, phone and supervisor's name:

PERSONAL INFORMATION -- Page 3

What is/are your drug(s) of choice?

How long have you had this choice?

Do you have a sponsor?

If Yes, please give full name and phone#:

Name of person(s) authorized to release information to:

Their relation to you:

Their phone number(s):

How did you discover Serenity Now?:

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