Resident Intake Application

Resident Intake Application

Apply for structured sober living housing at Restoration Living. Please complete all required sections for consideration.
SECTION 1 — PERSONAL INFORMATION

All fields in this section are required.
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Marital Status

Other
Gender

Other (specify)
SECTION 2 — EMERGENCY CONTACT

All fields in this section are required.
Emergency Contact Name

First NameLast Name
Relationship to Emergency Contact
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
SECTION 3 — EMPLOYMENT & FINANCIAL INFORMATION

Employment and financial status.
Employment Status

Other
Employer Name
Employer Phone
Please enter a valid phone number.Format: (000) 000-0000.
Monthly Income Range
How will housing fees be paid?

Other
SECTION 4 — SOCIAL SERVICE NEEDS

Please indicate if you need assistance with any of the following. Required.
Do you need assistance with SNAP / Food Stamps?
Do you need assistance with State ID or Driver’s License?
Do you need assistance with a Primary Care Physician?
Do you need assistance with a Dentist?
Do you need Counseling / Therapy assistance?
Do you need Employment Placement assistance?
Other Social Service Needs (If none, write “N/A”)
SECTION 5 — RECOVERY & SUBSTANCE USE HISTORY

All fields in this section are required.
Substances of Choice (Select all that apply)

Other
Most Recent Sobriety Date

MonthDayYear
Date
Longest Period of Sobriety (please specify duration)
Longest Period of Active Use (please specify duration)
Recent Substance Use (Past 6 Months)
Completed Detox?
If yes to Completed Detox — When and Where?
Previous Sober Living?
If yes to Previous Sober Living — Name and Location
12-Step Participation?
If yes to 12-Step Participation — Which Program?
Sponsor Name
Sponsor Phone
Please enter a valid phone number.Format: (000) 000-0000.
SECTION 6 — TREATMENT HISTORY

Required. Please provide your treatment history. Add all applicable entries.
Treatment History
SECTION 7 — LEGAL INFORMATION

All fields in this section are required.
Felony conviction history? If yes, please explain.
Registered sex offender?
History of violent offenses? If yes, please explain.
Pending charges? If yes, please explain.
DUI history? If yes, provide details.
Currently on parole or probation? If yes, provide officer name & phone.
Involved in Drug Court or Mental Health Court?
SECTION 8 — MEDICAL & SAFETY HISTORY

All fields in this section are required.
History of seizures? If yes, last occurrence.
History of overdose? If yes, how many.
History of suicide attempts? If yes, provide details.
Chronic medical conditions?
Allergies? If yes, describe.
Primary Physician (Name / Phone)
Preferred Hospital
SECTION 9 — MEDICATION INFORMATION

Please provide all current medications.
Medication Information
SECTION 10 — INSURANCE INFORMATION

Insurance details for verification.
Insurance Company
Policy Number
Group Number
Insurance Phone
Please enter a valid phone number.Format: (000) 000-0000.
Medicare / Medicaid?
SSI / SSD?
Should be Empty:

Resident Intake Application

SECTION 1 — PERSONAL INFORMATION

SECTION 2 — EMERGENCY CONTACT

SECTION 3 — EMPLOYMENT & FINANCIAL INFORMATION

SECTION 4 — SOCIAL SERVICE NEEDS

SECTION 5 — RECOVERY & SUBSTANCE USE HISTORY

SECTION 6 — TREATMENT HISTORY

SECTION 7 — LEGAL INFORMATION

SECTION 8 — MEDICAL & SAFETY HISTORY

SECTION 9 — MEDICATION INFORMATION

SECTION 10 — INSURANCE INFORMATION