JUST BREATHE SOBER LIVING - Level 2 Intake Form
SECTION 1: RESIDENT INFORMATION
Full Legal Name:
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:
History of Overdose?
Completed Treatment?
SECTION 4-6
SECTION 4: LEGAL STATUS
*
On Probation
On Parole
Drug Court
Pending Charges
None
Probation Officer / Contact:
SECTION 5: MEDICAL & MENTAL HEALTH
SECTION 5: MEDICAL & MENTAL HEALTH
*
Diagnosed Mental Health Condition?
None
List of Conditions / Medications
List of Conditions / Medications
*
History of Suicidal Ideation or Attempts?
None
SECTION 6: EMPLOYMENT & FINANCIAL
*
Employed
Unemployed
SSI/SSDI
Recovery Works
SOR Funding
Employer Name
Weekly Income
SECTION 7-9
SECTION 7: RECOVERY COMMITMENT
*
Remain sober and drug-free
Submit to random drug screens
Attend required house meetings
Participate in recovery programming
Follow curfew and house rules
Contribute to chores and house responsibilities
SECTION 8: HOUSE FEES AGREEMENT
SECTION 9: ACKNOWLEDGEMENTS
Applicant Signature:
Signature
Date:
SECTION 10: ZERO TOLERANCE & GOOD NEIGHBOR POLICY
*
Drug or alcohol use
Violence or threats
Theft
Possession of weapons
Sexual misconduct
Tampering with drug screens
SECTION 10.2: ZERO TOLERANCE & GOOD NEIGHBOR POLICY
*
No loitering
No loud music
Respect community property
Maintain cleanliness
No illegal activity
SECTION 11: CONFIDENTIALITY & INFORMATION RELEASE
Communicate with Probation
Communicate with Treatment Provider
Communicate with Recovery Works
Verify employment
Signature
Date:
SECTION 12: INDIVIDUALIZED RECOVERY PLAN & ADMISSION DECISION
Employment Goal:
Recovery Goal
ADMIN SECTION
Admission Approved
Admission Denied
Bed Assignment
Move-In Date:
Staff Signature
Staff Signature
Continue
Continue
Should be Empty: