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Pre-Admission Form

Live Free Recovery and Sober Living

Contact Us At: (888)610-2847

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Live Free Recovery and Sober Living Pre-Admission Form

Please fill out the form below and one of our staff members will contact you shortly.

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Name*

First Last

Date of Birth*

Phone*

Email*

Mailing Address*

Address Line 2

City*

State*

Postal Code*

Country*

Drug Of Choice?

Date Of Last Use?

Who Is Financially Responsible For Your Stay?*

Other responsible party information

Relationship

Other responsible party's relationship to you

Other Phone

Their mailing address

Other mailing address line 2

Other City

Other State

Other ZIP

Other Country

Insurance Name

Policy Number

Insurance Phone

How Did You Hear About Live Free (Family, Treatment Center, Therapist)?

Do You Have Allergies (Food or Environment)?

What Hobbies Or Interests So You Have (Exercise, Music, Hiking, Etc.)?

Mental Health

Do You Have A Mental Health Diagnosis?*

Yes

No

What Medications Are You Currently Taking?

Have You Ever Attempted Suicide?*

Yes

No

Do you have a history of self-injurious behavior?*

Yes

No

Are You Currently On Probation Or Parole? If So Where?

Have You Ever Been Convicted Of Arson?*

Yes

No

Have You Ever Been Convicted Of A Sex Crime?*

Yes

No

Live Free asks that you be willing to commit to staying here for a minimum of 3 months and also be willing to fully participate in our program:

Is This Something You Are Willing To Commit To? **

Yes

No

What Date Are You Looking To Be Admitted?*

Emergency Contact Information (Name & Phone):*

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Published on: 2021-09-30
Updated on: 2023-02-16

Contact

For Admissions, Call:
(888) 610-2847
[email protected]

Live Free Recovery Services and Sober Living:
70 Kelley Street
Manchester, NH 03102

Live Free Recovery Services and Sober Living:
17 Kit St
Keene, NH 03431

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