APPLY TODAY
Home
About Us
How We Help
Our Program
Our Program
What To Expect
FAQs
Locations
Contact
Apply Today
Recovery in Unity Works
Apply Today
"
*
" indicates required fields
Name
*
First
Last
Email
*
Enter Email
Confirm Email
Phone
*
Date of Birth
*
Month
Day
Year
Are you currently employed?
*
Yes
No
Who was your last employer?
*
Company Name
*
Employer Contact
*
First
Last
Employer Phone
*
Please list ALL medications you are taking:
*
Add
Remove
Do you have a reliable means of transportation?
Yes
No
When is your sobriety date?
*
Month
Day
Year
What is your primary drug of choice?
*
Do you have any other information you'd like to share?
Consent
*
I grant Unity Sober Living permission to use my answers in gathering statistical data for future analysis. No name or contact info will be sold or shared.
Privacy
*
I have answered these questions honestly and to the best of my knowledge. I understand that this information will not be shared with anyone outside of Unity Sober Living Staff and is intended for admission purposes only.
Email
This field is for validation purposes and should be left unchanged.