HIPAA Compliant Statement

Pittsburgh Sober Living strictly follows the guidelines of the Health Insurance Portability and Accountability Act (HIPAA). The contents of your faxed communication are protected by state and federal law. This privileged and confidential information is intended only for use by the Pittsburgh Sober Living staff to fulfill your request.

Pittsburgh Sober Living is committed to your online security. We use SSL technology to securely process your request for information and with our online forms. SSL (Secure Sockets Layer) is an industry standard for encrypting private data sent over the Internet. In other words, we keep your information safe.

• Sex of Tenant? *FemaleMale
• First Name: *
• Last Name: *
• Date of Birth: *
• Social Security Number (only numbers; no dashes): *
• Race: 



 
• Applicant's Current or Last Mailing Address (do not put a PSL house address)
• Street Address:
• City:
• State: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
• Zip:



 
• Applicant's Telephone Number
• Applicant's Email Address
• Emergency Contact Name
• Emergency Contact Telephone Number
• Sobriety Date
  
  
  
  
• Are you currently attending Rehab Treatment/Therapy? * YesNo
• If you are currently attending Treatment/Therapy, where are you attending Treatment/Therapy?
• If you are currently in Treatmeant, who is your counselor?
• If you are not currently in Treatment, What was your Last Treatment Center
• Are you currently or planning on attending any outpatient or mental health therapy? YesNo
• Insurace Carrier
• Insurace Plan





• Who is your employer?
• What is the telephone number of your employer?




• Parole/Probation Officer Name
• Parole/Probation Officer Telephone Number




• Are you required to register as a sex offender? *YesNo




• Name of any agencies that are providing assistance
• Your Agency Contact
• Telephone Number of Your Agency Contact




• Veteran?: *YesNo




• Medical Conditions, if applicable



• Medications, if applicable



• Allergies, if applicable