SOBER LIVING AT THE STABLES
Resident Intake Form (2026)
Move-In Date:
-
Month
-
Day
Year
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Resident – General Information
Name
First Name
Middle Initial
Last Name
Nickname:
Phone #:
Format: (000) 000-0000.
Email:
example@example.com
Secured Information
Date of Birth:
-
Month
-
Day
Year
Date
SSN/ITIN #:
ID/CDL #:
Military ID #:
Marital Status:
Spouse Name:
Spouse Phone:
Format: (000) 000-0000.
Financial Information
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Monthly Income 1:
Source:
Monthly Income 2:
Source:
Other Monthly Income:
Available Savings:
Monthly Expenses (check all that apply):
Cell Phone
Car
Loans
Other
Total Monthly Expenses:
Emergency Information
Emergency Contact #1
Emergency Contact #1 Name
First Name
Last Name
Phone #:
Format: (000) 000-0000.
Email:
example@example.com
Relationship:
Emergency Contact #2
Emergency Contact #2 Name
First Name
Last Name
Phone #:
Format: (000) 000-0000.
Email:
example@example.com
Relationship:
Medical Information
Do you have medical insurance?
Yes
No
Provider:
Policy/Member ID #:
Contact #:
Format: (000) 000-0000.
Do you have any allergies or dietary restrictions?
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List current medications:
List food/beverage preferences or restrictions:
Do you have any chronic medical conditions we should be aware of?
Do you require any special medical equipment?
Resident Suitability Questionnaire
Can you walk independently?
Yes
No
Sometimes
If No/Sometimes, explain:
Can you participate in household chores? (Circle)
Yes
No
If No, explain:
Can you bathe and dress yourself? (Circle)
Yes
No
If No, explain:
Do you bathe regularly? (Circle)
Yes
No
Do you have any issues with bladder control? (Circle)
Yes
No
Sometimes
If Yes, explain:
Legal / Supervision Status
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Are you on probation or parole? (Circle)
Yes
No
Officer Name:
End Date:
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Month
-
Day
Year
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Officer Phone #:
Format: (000) 000-0000.
Resident Suitability Questionnaire (Continued)
Do you smoke? (Circle)
Yes
No
If yes, explain:
Are you currently in recovery from addiction? (Circle)
Yes
No
If yes, explain:
Typical bedtime:
Hour Minutes
AM
PM
AM/PM Option
Do you have regular medical or counseling appointments?
Food Preferences
Foods you do NOT like:
Favorite foods: Meats:
Vegetables:
Other:
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Lifestyle & Compatibility
Activities you enjoy:
Any concerns living with roommates:
Do you work or volunteer?
Anything else we should know:
Acknowledgment
I certify that the information provided above is true and accurate to the best of my knowledge. I understand that providing false or misleading information may result in denial of admission or termination of residency at Sober Living at The Stables.
Signature:
Date:
-
Month
-
Day
Year
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