Reset currently has houses in Newport, KY and Lawrenceburg Indiana (Levi’s House). Do you have a preference into which home you would like to be placed?

Yes

No

Name *

First Name

Last Name

Phone *

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Birthdate *

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Please check all that apply to you. *

I have been sober for at least 30 days.

I am not a registered sex offender.

I am at least 21 years of age.

I am willing to commit to a 12-18 month program.

I have read Reset's Policies

I have been administered a MAT in the past year (with the exception of Vivitrol)

If accepted, when would you be able to move in? *

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Do you have a significant other? *

Yes

No

Do you have children? *

Yes

No

Have you ever served in the military? *

Yes

No

Do you have any legal issues? *

Yes

No

When was the last time you used alcohol or drugs (including cannabis and marijuana)? *

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DD

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Have you ever tried to stop before? *

Yes

No

Did you experience any medical complications? *

Yes

No

Have you ever been in a treatment program or a detox facility? *

Yes

No

Primary Addiction - Date of Last Use *

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DD

YYYY

Secondary Addiction - Date of Last Use *

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DD

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Do you have any physical disabilities? *

Yes

No