Name
*
First Name
Last Name
Date of Birth
MM
DD
YYYY
Gender
Pronouns
Race/Ethnicity
Previous Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Email
*
Marital Status
Single
Married
Divorced
Other
Emergency Contact: Name and Relationship
Emergency Contact Phone Number
(###)
###
####
Employment Status: Are you currently employed?
If yes, list Employer:
Financial Support: Can you afford program fees or have assistance available?
Vehicle Information: Will you be bring a vehicle to the residence?
If yes, complete list the Year, Make/Model, Color, and your Insurance Provider:
Are you In Recovery?
*
Do you believe you need detoxification services?
Are you currently in treatment for substance use (e.g., therapy, PHP, IOP)?
If yes, please specify:
What is your Drug(s) of Choice?
Sobriety Date
MM
DD
YYYY
Do you have a sponsor?
Are you open to working a 12-Step program?
Recovery Goals: How can we assist you in reaching your recovery goals?
Do you have any medical issues, psychiatric conditions, or mental health diagnoses?
If yes, please specify:
Do you have any known allergies?
If yes, please specify:
Have you been tested for HIV?
If yes, what were your results:
Have you been tested for Hepatitis C?
If yes, what were your results:
Do you have any disabilities or health conditions you would like to disclose?
If yes, please specify:
Are you currently enrolled in a Medication-Assisted Treatment (MAT) program?
If yes, please provide your Prescribing Physician's Name and Phone Number:
Do you agree to store your medications as per our policy?
Do you agree to take your medications as prescribed?
Do you agree to not disclose your medications to other residents?
Have you traveled out of the country in the last 30 days?
Have you been in contact with anyone with an infectious disease?
Have you been tested for COVID-19?
Date of last test:
MM
DD
YYYY
Results of last test:
Have you experienced an Overdose?
Have you ever attempted to take your own life?
Have you ever been Hospitalized?
Have you ever experienced any Hallucinations?
If yes to any of the above, please provide details:
Do you have a history of harm to yourself or others?
If yes, please describe the incident and any treatment received:
Do you have any current or past criminal charges?
If yes, please specify:
Are you court-ordered to sober living or currently on probation?
If yes, please specify:
Are you a registered sex offender?
If yes, please specify:
Are you on community control or house arrest?
If yes, please specify:
Electronic Signature Consent
By typing your full name below, you acknowledge and agree that your electronic signature is the legal equivalent of your handwritten signature. You confirm that the information provided is accurate to the best of your knowledge, and you consent to the terms outlined in this document.
Date
MM
DD
YYYY
