Konnect Recovery House Intake Questionnaire

Welcome to Konnect Ministries Recovery House!

We are a faith-based organization dedicated to supporting individuals on their journey to recovery from addiction and mental health challenges. This intake questionnaire is designed to gather important information to help us determine if our program is a good fit for your needs.

Instructions:

Contact Information: Please provide your basic contact details so we can stay in touch with you throughout the intake process.
Personal Data Questions: Answer the personal questions as completely as you can. These questions help us understand your background, current situation, and specific needs.
No Wrong Answers: There are no "wrong" answers. We want to get to know you better, so please be honest and thorough in your responses.
Non-Applicable Questions: If a question does not apply to you, simply write "none" and move on to the next one.
Follow-Up: A member of our staff will follow up with you within 48 hours to discuss your application and provide further guidance.
For best experience, please use landscape orientation (sideways) on your phone or mobile device when filling out this form.

Thank you for taking the time to complete this questionnaire. We look forward to learning more about you and supporting you on your recovery journey

Name*

First NameLast Name

Preferred Name (Alias)*

Date*

Date

Email Address*

example@example.com

Detention Facility (if applicable:)

Inmate # (if applicable):

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Sexual Orientation*

HeterosexualGayBi-Sexual

Phone Number*

Please enter a valid phone number.

Date of Birth*

Date

Age*

Do you have a valid driver's license?*

State*

DL Number*

Expiration Date*

Date

Secondary/Emergency Contact (Name, Relationship, and Telephone Number) With your permission, Konnect might contact this person about your application.*

Where are you currently living? Please provide the address if you have one and explain how your living situation impacts your recovery.*

What do you hope to accomplish by living at Konnect Recovery House?*

What is your drug (example: heroin, alcohol, meth, etc...) of choice?*

When is the last time you drank or used substances? How much did you use?*

Are you currently detoxing from any alcohol or drugs?*

YesNoMaybe

If you are detoxing, please describe your detox symptoms and list what drugs or alcohol you have recently taken and when. *

Have you ever overdosed on drugs or drank to the point you had alcohol poisoning? If yes, please give approximate dates below. *

Have you ever been administered Narcan or Naloxone? If yes, how many times?*

Have you been in recovery before? Have you been to treatment? Take a moment to describe your past successes and challenges in recovery. *

How have drugs and alcohol impacted your life?*

Which areas of your life have been impacted by your substance abuse?*

When did you first notice you had a problem with drugs/alcohol? Did you notice or did someone bring it to your attention?*

Do you want to stop using drugs and alcohol?*

YesNoMaybe

Do you want to stop using drugs and alcohol?*

Do you have any ongoing medical conditions? If so please describe them below*

Please list all prescription and over the counter medications below, the dosage, and how often you take them. *

Are you able to take medications as prescribed without assistance?*

YesNoMaybe

Do you have any issues with the following?*

Please list any psychiatric conditions you are being treated for.*

Have you ever attempted suicide or been hospitalized for suicidal thoughts/ideation?*

YesNo

Are you currently facing any criminal charges or are you on probation? If so, please list the charges/convictions and your current obligations to the Court below. *

Are you required to register as a sex offender?*

YesNo

Have you previously served time in jail or prison? If so, please give a brief summary of what that experience was like. *

Do you own a vehicle that you will be bringing to Konnect Recovery House?*

YesNo

Are you currently in a romantic relationship? If so, explain how that relationship might affect your stay at Konnect Recovery House.*

Do you have children? If so, describe your relationship with them and describe how it might affect your stay at Konnect Recovery House.*

Tell us a little bit about your interests and hobbies:*

Are you currently employed, volunteering, or in a work program? If yes, explain:*

How soon are you seeking a bed license?*

I understand that upon approval of my application and move-in, I must comply with all of the residents rules and policies contained in the Konnect Recovery House intake packet. I understand that these Rules and Policies may change from time to time at the discretion of Konnect Recovery House.

I further understand that my residency at Konnect Recovery House is temporary, transitional, and continues at the discretion of Konnect Recovery House staff. I acknowledge that, as a resident of Konnect Recovery House, I am a bed licensee and not a tenant, and that I have no tenancy rights or interests. As such, I agree that I can be discharged from the premises immediately should it be determined by Konnect Recovery House leadership that it is in the best interest of other Konnect Recovery House residents, the recovery environment as a whole, or the surrounding community that my bed license be immediately terminated.

I release Konnect Recovery House from any and all liabilities associated with my residence at Konnect Recovery House House. I have answered each question honestly. My goal in completing this application is to live a life free of substance abuse and misuse.

Acknowledgement and Acceptance *

Signature*

Residential Intake Questionnaire

Acknowledgement and Release