INTAKE FORM

INTAKE FORM

Welcome to Still Horizon Housing. We provide sober living and transitional housing for individuals rebuilding after addiction, incarceration, or crisis. Our program includes peer support, trauma-informed care, and life-skills coaching. Housing is $600/month and includes a fully furnished room and all utilities. Please complete the application below. Once reviewed, we’ll contact you with next steps and, if approved, provide a confirmation letter for your release or referral process. We’re here to support your fresh start.
End of Probation Date*

MonthDayYear
Date
First Name*
Middle Name
Last Name*
Nickname
Preferred Pronoun

He/HimShe/HerThey/ThemOther
Gender Identity

MaleFemaleNon-binaryPrefer not to sayOther
Current Offense
Term of Sentence
Time Served
Date of Next Parole Hearing
Earliest Expected Release Date
Additional offenses, sentences and time served
What have you learned from your past experiences, and what steps are you taking to build a more stable and positive future?
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
ID/CDL Number
Marital Status

SingleMarriedDivorcedWidowedSeparated
Spouse's Name
Spouse's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Monthly Income 1
Source of Income 1
Monthly Income 2
Source of Income 2
Other Monthly Income
Available Savings
Cell Phone Expenses
Car Expenses
Loans and Debts
Other Expenses
Total Monthly Expenses
Emergency Contact 1 - First Name

First NameLast Name
Emergency Contact 1 - Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 1 - Email
example@example.com
Emergency Contact 1 - Relationship
Emergency Contact 2 - First Name

First NameLast Name
Emergency Contact 2 - Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 2 - Email
example@example.com
Emergency Contact 2 - Relationship
Have you experienced any of the following? (Check all that apply or leave blank):

Domestic violenceSexual abuse or assaultHuman trafficking or exploitationUnsafe or unstable housingEmotional or psychological abuse
Is there anything specific we should know to help ensure your safety and comfort while in our program?
Would you like to speak privately with staff about any past trauma or special needs?

YesNoMaybe later
Do you have Medical Insurance?

YesNo
Medical Insurance Provider
Contact Number for Medical Insurance
Please enter a valid phone number.Format: (000) 000-0000.
Allergies/Dietary Restrictions
Medication List
Food/Beverage Preferences
List food items that you do not like:
Other Medical Notes
Do you have any chronic medical issues we should be concerned about? (Example: Diabetes, COPD, etc.) Please provide details below:
Do you have any special medical equipment?
COVID-19 Exposure in Last 14 Days?

YesNo
If Yes, please explain
Current Symptoms (Select all that apply)

FeverDry CoughFlu-like Symptoms
Ability to walk independently?

YesNoSometimes
Can you participate in household cleaning and chores?

YesNoSometimes
Can you bath and dress yourself?

YesNoSometimes
Do you bath every day?

YesNoSometimes
Do you have any issues with bladder control?

YesNoSometimes
Do you smoke?

YesNoSometimes
Do you have any regular medical appointments? Please explain.
Are you recovering from any addiction that we should be aware of?(Circle) Yes No IF YES, please explain:
List concerns you may have living with a roommate?
List Activities you enjoy doing:
Do you work or volunteer anywhere?
List ANYTHING else we should be concerned about.
Signature
Still Horizon Housing provides sober living and transitional housing focused on safety, structure, and recovery. While we offer support and guidance, we do not guarantee employment assistance.

By submitting this application, you agree to follow all house rules outlined in the Program Agreement and any additional guidelines shared upon acceptance.

We are here to support your fresh start and ask that you commit to making the most of this opportunity.
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