Sober Living Application - Private Pay
Men's Seneca House - Denver - This Form Takes Approx 3-5 Minutes to Complete
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender Assigned at Birth?
*
Male
Female
Do you have Colorado Medicaid?
Yes
No
Not Sure
Which house are you applying for? Athens House (Medicaid Program) or Seneca House (Cash Pay)
SafeSide House
Seneca House
Not Sure
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
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
*
Submit
Submit
Should be Empty: