Striving to Thrive Intake Form

Sober Living Home Resident Application

Please complete this application to be considered for residency. Provide accurate information and upload any relevant medical documentation.
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Current Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Have you previously lived in a sober living home?*

YesNo
Are you currently enrolled in a recovery program?*

YesNo
Which substances are you in recovery from?*

AlcoholOpioidsStimulantsMarijuanaBenzodiazepinesOther
Do you have a legal guardian or case manager?*

YesNo
Medical History

Please provide information about your medical background.
Do you have any of the following medical conditions?

DiabetesEpilepsyHeart DiseaseMental Health DiagnosisOther
Please list any medications you are currently taking prescribed by a License Physician or over the counter.
Allergies or dietary restrictions (if any)
Are you currently on Parole or Probation*

YesNo
If yes, please list your PO or Parole Office name and Phone Number
Are you currently in a shelter, hospital, or treatment center?*

YesNoOther
Do you have any mental health diagnoses?*

YesNo
If Yes, What is the diagnoses?
Are you currently employed?*

YesNo
If No, How are you going to pay the weekly fee?
What are your goals while in our program

Find stable housingMaintain sobrietyGain employmentImprove mental healthBuild supportive relationshipsDevelop life skillsOther
Upload Driver License or Identification Card

Cancelof
Signature (Please sign below to confirm your application and consent)*

Powered by Jotform SignClear
Should be Empty:

Sober Living Home Resident Application

Emergency Contact Information

Medical History