NEW ADMIT FORM
Please complete each item below:
Admission Date
-
Month
-
Day
Year
Date
Guest Name
First Name
Last Name
Guest Phone Number
Please enter a valid phone number.
House Manager’s Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Sobriety Birthday:
-
Month
-
Day
Year
Date
Monthly Guest Fees/Rent Amount
What day of the month will your rent be due on? This will most often be the day of the month you moved in:
Will you or a loved one be responsible for paying the monthly guest fees? Please write their name here below. If you are paying your own rent just write myself:
What payment schedule are you committing to pay on: weekly, bi monthly or monthly?
Please Select
Weekly
Bi Monthly
Monthly
What platform will you be most likely be using to submit your guest fee payments through:
Please Select
Credit or Debit Card
Cash App
Venmo
Zelle
Cash
Check
Gender
Female
Male
Other
Please take a self photo from your shoulders and above using this device:
Please write any of your doctors full names to include General, psychiatric, psychological or any others you visit.If you can add phone numbers next to their names its even better:
Please any allergies to medication, food or all other:
Please List each name of all medications you take:
Are you currently on a suboxone MAT treatment program?
Please Select
Yes
No
Do you get injections of vivitrol opioid blocker or take vivitrol in any other form?
Please Select
Please list any mental health diagnosis you have:
Are you having or sometimes have suicidal or homicidal thoughts?
Please Select
Do you have a vehicle you will be parking at the house?
Please Select
Yes
No
Please write the year, make and color of your car.
Do you have your own AA or NA Big Book?
Please Select
Yes
No
If you selected no: Would you like us to provide you a Big Book?, please select if you want the AA or NA version:
Please Select
Narcotics Anonymous
Alcoholics Anonymous
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Please describe any of your past work experience; training or licenses:
What is your current Employment Status?
Employed
Unemployed
Retired
Other
Please list and describe what type of job you would ideally want? List as many as you want starting with the most wanted occupation first then scaling down from there.
Please list your main drug of choice:
Other than your drug of choice, what other drugs do you often or rarely use? Please list the name of each drug below:
Have you taken a drug test yet upon moving into the house?
Please Select
Yes
No
Agreement
Please attach a clear photo of your drug test cup showing the results:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please list the names of the drugs you tested positive during your initial move in drug test:
I’m
Do you currently have a valid government ID or drivers license?
Please Select
Yes
No
Please attach a picture of the front of your government ID
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Do you have a physical social security card currently in your possession?
Please Select
Yes
No
Please attach a photo of your security card?
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Would you like our assistance with helping obtain any of the following items?
Drivers license or government ID
Social Security Card
EBT card food benefits
Private medical insurance
Medicare of medicaid medical insurance
Food donations
Clothes donations
Have you been shown where the narcan is kept in house?
Please Select
Have you been read the house rules and understand each of them?
Please Select
Yes
No
Please check the list of forms below that you've read and signed. This will confirm you understand our policies and procedures.If you have not completed any of these, please ask the house manager to provide you with that missing form:
Guest Agreement
Refund Policy
Curfew Policy Form
Assessment Questionaire
How long do you intend, plan or hope to stay here in our sober living home?
Please Select
Less than 1 month
1 month
2-3 months
4-6 months
7-12 months
1 year or more
Do you currently have a sponsor who you regularly communicate with?
Yes
No
Would you like us to help you find a sponsor?
Yes
No
Not sure yet
Did you bring groceries when you arrived or plan to soon?
Please Select
Yes
No
Please list the first and last name of any friends or family you approve us to release information to on your behalf. Our only intention when we do share is to help you succeed in your recovery and keep you safe:
Do you use any tobacco or smoking products?
Cigarettes
Vape
Chewing Tobacco
Which property location are you living at?
Sheery
Crystal Lake
Alamandine
Dancing Flame
Do have food or resources to buy food for the next 48 hours or until you have groceries?
Please Select
Yes
No
If there is anything else you want us to share or make us aware of? Feel free to list any thoughts, suggestions, questions or concerns? If nothing comes to mind than just leave this blank:
Guest Signature
Submit
Should be Empty: