Client Intake Application

Client Intake Application
Program Application

Men & Women of Truth Sober Living is a short to long term transitional living facility. Our clients are required to work on a 12-Step Program, attend meetings, gain employment, and must follow all house rules and regulations. We provide one-on-one coaching and additional therapy if needed.** FAILURE TO ANSWER THESE QUESTIONS CAN RESULT INTO DENIED APPLICATION.**
Applicant Info

First NameLast Name
AgeSocial #
DOB

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
E-mail
example@example.com
Do you have medical insurance?
Veteran? Branch?
Is your Driver’s License
DL#/STATE
DUI/DWI? #OF TIMES?
Do you need transportation?
About You
What employment skills do you have? Trade?
Are you on Probation or Parole? For? PO info?
Any kinds of pending charges? If yes, then what?
Misdemeanor or Felon?Are you a registered Sex Offender?
Do you suffer from substance abuse or mental abuse?
What are your triggers? How do you deal with them?
DRUG OF CHOICE

NameClean date? Last episode?
Why are you applying for transitional housing?
What are your short team goals?

Previous rehab facilities:

Rows	Treatment Program	Reason for Living?
Date
Date
Date
Date

Detox completed?
How many times have you relapsed or is this your first time attempting recovery?
Do you have any health issues or disorders?

Current medications taken:

Rows	Medicine	Dosage
How often
How often
How often
How often

Do you smoke?
Are you vaccinated?
HIV/AID, HEP C, HEP B?
If yes, which one and when:
TB Tested?
If yes, when:
Emergency Info
Emergency Contact

NamePhone
Relation?
Marital Status?

Partner Clean/Using/Mental Health?

ChildrenAges

Religion
Have you been diagnosed with any mental illness? Pleas list below:
What recreational drugs have you used in the past? How often?
Describe yourself in a high or mental state:
What makes you want to be clean and stay clean or in good mental health?
Do you have a sponsor or therapist?
Name
PhoneFormat: (000) 000-0000.
Your Support System
Tell us about your support system:
Do they support you?
Is there any family history or drug, alcohol, or mental illness?
Men & Women of Truth Sober Living is an opportunity for a new beginning and clean and healthy living. What would you do to be successful at Men & Women of Truth Sober Living?
How did you hear about us?
Monthly Program Fees:
Consent to Verification
I warrant, to the best of my knowledge, all of the information provided in this Application is true, accurate, complete and correct as of the date of this Application. If any information provided by me is determined to be false, such false statement will be grounds for disapproval of my Application or termination of Men & Women of Truth Program.

I understand and agree: (i) this is an application only and does not guarantee that I will be accepted into Men & Women of Truth and (ii) Lessor may accept more than one application for the Program and, using their sole discretion, will select the best qualified applicant. I hereby authorize the Lessor to verify the information provided.
Do you read this Agreement and agree to the terms and conditions
Signature
Date

MonthDayYear
Date
Should be Empty:

Client Intake Application

Program Application

About You

Emergency Info

Your Support System

Consent to Verification