House of Serenity Intake Form

House of Serenity Intake Form

Please complete all sections accurately to assist with your application review.
Personal Information
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender

Other
Detailed Contact Information
Current Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Emergency Contact
Emergency Contact Name

First NameLast Name
Relationship to You
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Email Address
example@example.com
Medical History
Do you have any diagnosed mental health conditions?
If yes, please specify your mental health diagnoses.
Are you currently prescribed any medications?
If yes, please list your current medications.
Do you have any allergies?
If yes, please list your allergies.
Substance Use History
Have you ever used substances (alcohol, drugs, etc.)?
If yes, please describe your substance use history (types, frequency, duration).
Sobriety Date

MonthDayYear
Date
Legal/Probation/Parole Status
Are you currently on probation or parole?
If yes, please provide details (officer name, contact, requirements).
Employment/Income Details
Current Employment Status

Other
Source(s) of Income

Other
Daily Schedule
Please describe your typical daily schedule (work, activities, routines).
Transportation
How will you get to and from the house?

Other
Program Expectations Acknowledgment
House Rules Acknowledgment
Consent Forms
Digital Signature
Date Signed

MonthDayYear
Date
Should be Empty:

House of Serenity Intake Form

Personal Information

Detailed Contact Information

Emergency Contact

Medical History

Substance Use History

Legal/Probation/Parole Status

Employment/Income Details

Daily Schedule

Transportation

Program Expectations Acknowledgment

House Rules Acknowledgment

Consent Forms