J Baker House Intake Form
After this short form, we will contact you to move forward with accommodations.
* Indicates required question
Full Name *
Your answer
Email *
Your answer
Phone # *
Your answer
How long have you been Sober?
Your answer
Drug of Choice?
Your answer
Are You Currently Homeless? *
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Yes
No
Have you ever Lived in a Sober Home? *
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Yes
No
Are you on Probation/Parole? *
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Yes
No
Are you Employed? *
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Yes
No
Do you have a State voucher? *
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Yes
No
Comments
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