Form

JUST BREATHE SOBER LIVING - Level 2 Intake Form
SECTION 1: RESIDENT INFORMATION
Full Legal Name:
Preferred Name:
Age:
Phone Number:
Email Address:
Date of Birth:
Current Address:
Emergency Contact Phone:
Emergency Contact Name:
SECTION 2: REFERRAL INFORMATION
Referral Source / Agency:
Case Manager Name & Phone:
SECTION 3: SUBSTANCE USE HISTORY
Primary Substance:
Secondary Substances:
Date of Last Use*

History of Overdose?Completed Treatment?
SECTION 4-6
SECTION 4: LEGAL STATUS*

On ProbationOn ParoleDrug CourtPending ChargesNone
Probation Officer / Contact:
SECTION 5: MEDICAL & MENTAL HEALTH
SECTION 5: MEDICAL & MENTAL HEALTH*

Diagnosed Mental Health Condition?
List of Conditions / Medications
List of Conditions / Medications*

History of Suicidal Ideation or Attempts?
SECTION 6: EMPLOYMENT & FINANCIAL*

EmployedUnemployedSSI/SSDIRecovery Works
Employer Name
Weekly Income
SECTION 7-9
SECTION 7-9
SECTION 7: RECOVERY COMMITMENT*

Remain sober and drug-freeSubmit to random drug screensAttend required house meetingsParticipate in recovery programmingFollow curfew and house rulesContribute to chores and house responsibilities
SECTION 8: HOUSE FEES AGREEMENT
Weekly Rent:
Security Deposit:
SECTION 9: ACKNOWLEDGEMENTS
Applicant Signature:
Date:
SECTION 10: ZERO TOLERANCE & GOOD NEIGHBOR POLICY*

Drug or alcohol useViolence or threatsTheftPossession of weaponsSexual misconductTampering with drug screens
SECTION 10: ZERO TOLERANCE & GOOD NEIGHBOR POLICY*

No loiteringNo loud musicRespect community propertyMaintain cleanlinessNo illegal activity
SECTION 11: CONFIDENTIALITY & INFORMATION RELEASE

Communicate with ProbationCommunicate with Treatment ProviderCommunicate with Recovery WorksVerify employment
Signature:
Date:
SECTION 12: INDIVIDUALIZED RECOVERY PLAN & ADMISSION DECISION
Employment Goal:
Recovery Goal
Admission ApprovedAdmission Denied
Bed Assignment
Move-In Date:
Staff Signature
Staff Signature
Should be Empty:

JUST BREATHE SOBER LIVING - Level 2 Intake Form

SECTION 1: RESIDENT INFORMATION

Full Legal Name:

Preferred Name:

Age:

Phone Number:

Email Address:

Date of Birth:

Current Address:

Emergency Contact Phone:

Emergency Contact Name:

SECTION 2: REFERRAL INFORMATION

Referral Source / Agency:

Case Manager Name & Phone:

Primary Substance:

Secondary Substances:

SECTION 4-6

Probation Officer / Contact:

SECTION 8: HOUSE FEES AGREEMENT

Weekly Rent:

Security Deposit:

SECTION 9: ACKNOWLEDGEMENTS

Applicant Signature:

Date:

Signature:

Date:

SECTION 12: INDIVIDUALIZED RECOVERY PLAN & ADMISSION DECISION

Employment Goal:

Move-In Date: