• Sacred Ascent Sober Living Application

    Sacred Ascent Sober Living Application

    WELCOME HOME! At Hope Dealers Recovery & Wellness, we believe recovery is about more than putting down a substance. It is about rebuilding your life, discovering your purpose, establishing stability, and creating a foundation for long-term independence. We understand that recovery is not always a straight line. We believe in second chances, accountability, community, personal growth, and the opportunity to create a better future. We don't need you perfect. We need you ready. Please complete this application honestly and thoroughly. Your answers help our team understand your recovery goals,housing needs, and the support that may help you succeed. PRIVACY & CONFIDENTIALITY NOTICE Important: Please read before beginning your application. This application collects personal information and may include sensitive health-related information. Hope Dealers Recovery & Wellness Colorado LLC is committed to protecting applicant and resident confidentiality in accordance with applicable federal and Colorado privacy laws, including HIPAA and 42 CFR Part 2 where applicable.Information collected through this application is intended for admissions review, housing placement, appropriate support planning, and related authorized operations.Access to submitted information must be limited to authorized personnel with a legitimate need to know, who are subject to applicable confidentiality requirements, appropriate training, and information-security safeguards.Information will not be shared with outside parties except as permitted or required by applicable law, or through an appropriate, separately obtained authorization when required.Please review our Notice of Privacy Practices before submitting sensitive health information.
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Preferred Contact Method*
  • Do you have stable housing to transition from?*
  • Employment Status*
  • Gender*
  • Format: (000) 000-0000.
  • Date of Desired Move-In
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Last Use (Sobriety Date)
     - -
    2 digit month, 2 digit day, 4 digit year
  • Primary Substance(s) Used
  • Are you currently on any prescribed medications?*
  • Do you have any allergies (medication, food, environmental)?
  • Do you have any medical or mental health diagnoses?*
  • Do you have a primary care provider or therapist?
  • Do you have a history of violence (including domestic violence), arson, or sexual offenses?*
  • Are you currently on probation, parole, or facing legal charges?
  • Have you attended any treatment programs before?*
  • Are you consenting to work and participate in orientation, recovery activities, community responsibilities, working with a Peer Recovery Coach and applicable residence programming, with reasonable accommodations where appropriate?*
  • Hope Dealers Recovery & Wellness utilizes a 10-day introductory probationary period for new residents. This period is intended to help establish accountability, commitment to recovery, healthy routines, personal growth, and progress toward financial independence and independent living. Staff and residents will work together to establish goals, identify challenges, and develop a foundation for success. All applicable resident rights and accommodation protections remain in effect. Do you understand and agree to participate in this 10-day introductory period?*
  • Should be Empty: