Apply to Live At Legacy Please complete the form below, and one of our team members will be in touch with you shortly. Name * First Name Last Name Email * Phone * (###) ### #### Birthdate MM DD YYYY Sobriety Date * MM DD YYYY Expected Move-In Date * MM DD YYYY Are you or will you be taking any prescribed medications? * Yes No If yes, please list all prescribed medications. Emergency Contact Name First Name Last Name Emergency Contact Phone Number (###) ### #### Current Treatment Facility Counselor's Name and Contact Information Do you have any criminal convictions? * Yes No If yes, please explain. Are you willing to commit to sober living for 3 months? * Yes No Do you agree to our zero-tolerance substance abuse policy? * Yes No Thank you!
