Intake Form | Manna House

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Rebuilding Lives since 2011

Welcome to Manna House ministries

Serving Western Lake and Eastern McHenry Counties in Illinois

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INTAKE FORM

Thank you for your interest in Manna House Ministries. Please fill out the form below and someone will be in touch with you soon.

First name

Last name

Date of Birth

Month

Day

Year

Email

Phone

Current Address

What treatment center or sober living places have you been involved with either now or in the past? Please list name(s) and dates.

Do you attend a church? If so, what is the name of your church? Do you have a close relationship with members of your church?

How long have you been sober?

What 12 step fellowship do you attend? How often?

Have you taken all of the 12 steps in your program of recovery?

Yes

No

Are you currently sponsoring another member in a 12 step program?

Yes

No

(224) 573-9104 | mannarecovery@yahoo.com

Serving Western Lake County and Eastern McHenry County in Illinois

© 2026 Manna House. Rebuilding Lives, One Heart at a Time.

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