Sober Living Application - Medicaid Program
This Form Takes Approx 3-5 Minutes to Complete
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
What Program are you applying for?
*
Intensive Peer Program and IOP
Gender Assigned at Birth?
*
Male
Female
Do you have Colorado Medicaid?
*
Yes
No
Not Sure
Food is not provided in this program. Do you have Food Stamps?
*
Yes
No
I need help securing food.
If you have food stamps, which county is it through?
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Previous living situation (e.g., with family, alone, in transitional housing):
*
Employment:
*
Employed
Student
Unemployed
If employed, please provide your job title and employer:
*
Do you have a valid driver's license?
*
Yes
No
Do you own a vehicle?
*
Yes
No
What were your substances of choice (including drugs and alcohol)?
*
What is the longest length of time you have ever been sober?
*
When did you last use drugs or alcohol?
*
Are you currently in a treatment facility?
*
Yes
No
If yes, please provide the name and location of the facility, the length of your stay, and the expected completion date:
*
Do you currently have a sponsor?
*
Yes
No
Are you currently involved in any outside recovery services (e.g., counseling, 12-step groups, SMART Recovery, etc.)?
*
Yes
No
If Yes, please specify:
*
Have you ever been diagnosed with a mental illness?
*
Yes
No
If Yes, is it managed?
*
Yes
No
Have you ever attempted self-harm?
*
Yes
No
If Yes, how long ago did this occur?
*
Are you currently prescribed any medications including MAT (medication-assisted treatment, such as Suboxone, Methadone, or Naltrexone)?
*
Yes
No
If Yes, please list all your medications including dosage information.
*
Do you have any ongoing health issues or disabilities that require accommodation?
*
Yes
No
If Yes, please describe:
*
Are you currently required, or will you be required, to report to probation, parole, or any court?
*
Yes
No
If yes, please provide the name, contact information, and county of your reporting officer or agency.
*
Have you ever been convicted of a felony, including assault, arson, or sexual abuse?
*
Yes
No
If Yes, please explain.
*
What times are you available for a phone interview? (Select all that apply)
*
Mornings
Afternoons
Evenings
What days are you available for a phone interview? (Select all that apply)
*
Monday
Tuesday
Wednesday
Thursday
Friday
Name of Referral Source
First Name
Last Name
Email of Referral Source
example@example.com
Do we have your permission to be in contact with your referral source?
*
Yes
No
Tell us where you are currently at with your recovery, where you'd like to be, and how we can help you get there?
*
Submit
Submit
Should be Empty: