Stop procrastinating Get proper help and support to regain your life First step is to fill out our questionnaire First Name *Last Name *Phone *Email Address *Date Of Birth *MonthSelect month123456789101112DaySelect day12345678910111213141516171819202122232425262728293031YearSelect Year212421232122212121202119211821172116211521142113211221112110210921082107210621052104210321022101210020992098209720962095209420932092209120902089208820872086208520842083208220812080207920782077207620752074207320722071207020692068206720662065206420632062206120602059205820572056205520542053205220512050204920482047204620452044204320422041204020392038203720362035203420332032203120302029202820272026202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924How did you hear of us?Where were you born and raised?How's your relationship with your parents?GoodFairPoorDeceasedHow's your relationship with your siblings?GoodFairPoorI don't have anyRelationship StatusMarriedSingleIn a relationshipDivorcedWidowHow many children do you have?012345 or moreWhere are you currently employed?Are you on probation or parole?NoYesWhat are your drug's of choice?Are you involved with Mental Health?NoYesCounselor's First NameCounselor's Last NameAre you taking any medication?NoYesName of MedicationReason for taking?How often?Length of useHave you had suicide thoughts or attempted to committee suicide in the last yearNoYesPlease explain:Do you have a no contact or restraining orders(s) against you?NoYesPlease Explain:Are you in the process or have you ever registered as a sex offender?NoYesPlease Contact Us 805.689.0763Are you currently enrolled in an outpatient program?NoYesWhereDaysGroup TimeCounselor NameHave you ever been admitted into sober living before?NoYesPlease explain:Why do you think sober living will help you now?How have drugs managed your life?Why are you requesting help now and what is different?How will you pay for sober living?Are you willing to go through any lengths and follow all of Pathway to Healing's house rules?NoYesHow can Pathway to Healing help you?What is your sobriety date?MonthSelect month123456789101112DaySelect day12345678910111213141516171819202122232425262728293031YearSelect Year212421232122212121202119211821172116211521142113211221112110210921082107210621052104210321022101210020992098209720962095209420932092209120902089208820872086208520842083208220812080207920782077207620752074207320722071207020692068206720662065206420632062206120602059205820572056205520542053205220512050204920482047204620452044204320422041204020392038203720362035203420332032203120302029202820272026202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924Do you have a sponsor?NoYesFirst NameLast NameDo you have a pending court date?NoYesMonthSelect month123456789101112DaySelect day12345678910111213141516171819202122232425262728293031YearSelect Year212421232122212121202119211821172116211521142113211221112110210921082107210621052104210321022101210020992098209720962095209420932092209120902089208820872086208520842083208220812080207920782077207620752074207320722071207020692068206720662065206420632062206120602059205820572056205520542053205220512050204920482047204620452044204320422041204020392038203720362035203420332032203120302029202820272026202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924What courtroom?Judge's First NameJudge's Last NameAttorney First NameAttorney Last NameAttorney's Phone NumberThank youClick SEND We will contact you as soon as possibleSENDPlease do not fill in this field.
