FLORIDA SOBER HOUSE

For Every Problem there is a SOLUTION!

2303 Hollywood Bld # 8, Hollywood FL 33020

954-366-5646                                                Fax: 954-366-1832

Full Name: ______________________________________________________________________________ Date __/__/200_

Address: ______________________________________________________________________________________________

Current Telephone Number: __________________________________________________________________

Current Cell Phone Number: __________________________________________________________________

Date of Birth: ________________ Date of Last Use: ____________

Longest Period of Abstinence including:

Dates: ______________________________________

Drug(s) of Choice: ______________________________________________

Dual Diagnosis:

List current treatment, medications & attending psychiatrist: ______________________________________________________

Are you currently taking prescribed medications? If so, list them: ___________________________________________________

Are you allergic to any medications?: _________ If so, please list medications: _________________________________________

Other allergies?: _____________________________________________________________________________________________

Have you recently gained or lost weight?: _________ Amount of loss: _______________ Amount of gain: __________________

Current weight: _____________ Current height: ____________ Do you have a prior history of eating disorders?: ___________

Have you ever been hospitalized for an eating disorder?: _________ Current status of eating disorder: ____________________

Do you have a history of binging, purging, or diuretic or laxative use?: _________

Please list all treatment facilities you have attended including names & dates:

___________________________________ | ___________________________________ | ___________________________________

Did you complete these programs successfully?: _________ If not, why?: ______________________________________________

Do you mind if we contact these facilities to discuss your treatment there?: _________

Please list all psychiatric facilities you have attended including names and dates:

___________________________________ | ___________________________________ | ___________________________________

Please list any current legal problems (be specific about charges, upcoming trials/hearings, dates):

___________________________________ | ___________________________________ | ___________________________________

Please provide the names of counselors/therapists you are currently seeing with the telephone number:

___________________________________ | ___________________________________ | ___________________________________

Level of Education Completed: ______________________________

Marital Status: _________________________ Do you have a history of alcoholism or addiction in your family?: _____________

If yes, please list family members: _______________________________________________________________________________

Please list your vocational skills: ______________________________

Do you have a valid driver’s license? If so, please list: State: ________ License Number: _________________________________

Do you have a valid passport? If so, please list: Country: __________________ Number: ________________________________

Do you have a car that is registered? If so, please list: State: ________ Registration Number: _____________________________

Please list your hobbies and special interests: _____________________________________________________________________

What would you say are your best characteristics: _________________________________________________________________

Please provide the name & telephone number of your nearest relative:

Name: ___________________________ Relationship: _______________ Telephone number: _____________________________

Add any additional information that we may find important:

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

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When you have completed our application please fax it right away to:

954-366-1832