INTAKE FORM

ANEWA HOUSE INTAKE
Desired Move in Date

MonthDayYear
Date
Resident - General Information
First Name
Middle Name
Last Name

Last nameNickname
Preferred Pronoun
Gender Identity
Date of Birth
Email
example@example.com
ID Number
Military ID
Marital Status
Spouses Name
Spouses Phone
Are you Employed?

YesNo
If Yes, Name of Employer
Monthly Income
Other Income
What is the total of your monthly expenses
Emergency Contact
First, Last Name
Emergency Contact Phone
Relationship to you
Do you have medical insurance?
Provider
Health Card
Drug/ Alcohol History
What's your sobriety date

MonthDayYear
Date
Do you have a Sponsor?

YesNo
If Yes, What is your Sponsors Name?
What is your Sponsors Phone Number?
What is your drug of choice?
How long have you been using/ drinking?
Have you been to treatment/ sober living before? If so, where?
Are you currently prescribed and taking any medications for substance use treatment (e.g Suboxone, Methadone, Naltrexone, etc.)?

YesNo
If yes, please list the medication(s) and Dosage
Who is your prescribing physician or clinic?
Criminal History
Are you on Probation or Parole?

YesNo
Probation/Parole Officer Name
Probation/ Parole Contact Number
CDC
What are you on probation or parole for?
Are you a registered sex offender

YesNo
Medical History
Have you ever been diagnosed with a mental health condition?

YesNo
If yes, please list any diagnosed conditions
Are you currently prescribed any medication?

YesNo
If Yes, Please list all medications and Dosage
Do you have any chronic medical issues we should be concerned about? ( Diabetes, COPD, Epilepsy, etc)
If yes, Please provide details below
Do you have any special medical equipment
Do you have any allergies or dietary restrictions Provide details below
Can you participate in household cleaning and chores?

YesNo
Can you perform all of your activities of daily living?

YesNo
Do you have any issues with bladder control?

YesNo
List Activities you enjoy doing
About Me
List concerns you may have living with a roommate
What are your short and long term goals?
List ANYTHING else we should be concerned about
The information I have provided above is true and accurate to the best of my knowledge. I understand that if I have not provided true and accurate information that it will be grounds for eviction.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

ANEWA HOUSE INTAKE

Drug/ Alcohol History

Criminal History

Medical History

About Me