Pre-Admission Form

Live Free Recovery and Sober Living

Call Us: (888) 610-2847

Home » Application

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.

"*" indicates required fields

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

What Medications Are You Currently Taking?

Have You Ever Attempted Suicide?*

Yes

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

Yes

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

Have You Ever Been Convicted Of Arson?*

Yes

Have You Ever Been Convicted Of A Sex Crime?*

Yes

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

What Date Are You Looking To Be Admitted?*

Emergency Contact Information (Name & Phone):*

CAPTCHA

This field is for validation purposes and should be left unchanged.

Take the First Step Towards a Brighter Tomorrow

At Live Free Recovery, we’re committed to walking alongside you on every step of your journey. Our compassionate team is here to provide the guidance and support you need to overcome addiction and reclaim your life. Don’t wait—reach out today to speak with someone who truly understands your struggles and can help you take that important first step toward healing and a fresh start.

Your path to recovery starts here.

Rehabs in Keene, NH

Rehabs in Manchester, NH

Levels of Care

Specialty Programs

Structured Sober Living

Alcohol

Stimulants

Illicit Drugs

Benzodiazepines

Opioids

Admissions Department

Pre-Admission Form

Live Free Recovery and Sober Living Pre-Admission Form

Mental Health

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:

Did this article answer your questions?

Take the First Step Towards a Brighter Tomorrow