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.
SingleMarriedSeparatedDivorcedWidowedOther
MaleFemaleNon-binaryPrefer not to sayOther (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.
Employed Full-TimeEmployed Part-TimeUnemployedStudentDisabilityOther
Employer Name
Employer Phone
Please enter a valid phone number.Format: (000) 000-0000.
$0–$1,000$1,001–$2,000$2,001–$3,000$3,000+
Self-payFamily SupportState FundingInsuranceDisability IncomeOther
SECTION 4 — SOCIAL SERVICE NEEDS

Please indicate if you need assistance with any of the following. Required.
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Other Social Service Needs (If none, write “N/A”)*
SECTION 5 — RECOVERY & SUBSTANCE USE HISTORY

All fields in this section are required.
AlcoholOpioidsMethamphetamineCocaineBenzodiazepinesMarijuanaHallucinogensStimulantsDepressantsOther
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)*
YesNo
If yes to Completed Detox — When and Where?
YesNo
If yes to Previous Sober Living — Name and Location
YesNo
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.*
YesNo
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.*
YesNo
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.
YesNo
YesNo
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