Crossroads of Hope Sober Living
Resident Admission Application
Applicant Information
Full Name:
Date of Birth:
-
Month
-
Day
Year
Date
Age:
Gender:
Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Current Address:
Driver's License/State ID #:
Social Security Number (Optional):
Emergency Contact Information
Emergency Contact Name:
Relationship:
Phone Number:
Format: (000) 000-0000.
Alternative Phone Number:
Format: (000) 000-0000.
Address:
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Health Insurance Information
Insurance Provider:
Member ID Number:
Group Number:
Primary Care Physician:
Physician Phone Number:
Format: (000) 000-0000.
Substance Use History
Primary Substance(s) Used:
Alcohol
Marijuana
Cocaine
Methamphetamine
Heroin
Fentanyl
Prescription Opioids
Benzodiazepines
Other
List All Previous Substances Used:
Date of Last Substance Use:
-
Month
-
Day
Year
Date
Time of Last Substance Use:
Hour Minutes
AM
PM
AM/PM Option
Length of Sobriety:
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Have you ever overdosed?
Yes
No
If yes, please explain:
Have you completed treatment previously?
Yes
No
If yes, where and when?
Mental Health Information
Do you have any diagnosed mental health conditions?
Yes
No
Mental Health Diagnosis(es):
Depression
Anxiety
PTSD
Bipolar Disorder
Schizophrenia
ADHD
Other
Please list all mental health diagnoses:
Current Mental Health Provider:
Provider Phone Number:
Format: (000) 000-0000.
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Medication Information
Please list all current medications, dosage, and prescribing physician.
Medication Dosage Frequency Prescribing Physician
Do you self-administer medications?
Yes
No
Legal Information
Are you currently on probation?
Yes
No
Are you currently on parole?
Yes
No
Probation/Parole Officer Name:
Officer Phone Number:
Format: (000) 000-0000.
County of Supervision:
Any pending legal charges?
Yes
No
If yes, explain:
Employment & Income Information
Current Employment Status:
Full-Time
Part-Time
Unemployed
Student
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Disabled
Retired
Employer Name:
Income Source (Check All That Apply):
Employment
SSI
SSDI
Veterans Benefits
TANF
Family Support
Unemployment
Other
Monthly Income Amount:
Recovery Information
Current Recovery Program:
AA
NA
Celebrate Recovery
Recovery Works
Outpatient Treatment
Intensive Outpatient Program (IOP)
Peer Recovery Services
Other
Sponsor Name (if applicable):
Sponsor Phone Number:
Recovery Goals
What are your recovery goals while living at Crossroads of Hope?
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What strengths will help you achieve these goals?
What challenges do you anticipate in recovery?
Medical Information
Do you have any medical conditions that staff should be aware of?
Yes
No
If yes, please explain:
Any allergies?
Yes
No
If yes, list allergies:
Do you require any medical accommodations?
Yes
No
If yes, explain:
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Resident Agreement
I certify that the information provided in this application is true and accurate to the best of my knowledge. I understand that providing false information may result in denial of admission or discharge from Crossroads of Hope Sober Living.
Applicant Signature:
Date:
-
Month
-
Day
Year
Date
Staff Use Only
Application Received Date:
-
Month
-
Day
Year
Date
Interview Completed:
Yes
No
Drug Screen Completed:
Yes
No
Drug Screen Results:
Admission Decision:
Approved
Denied
Waitlist
Move-In Date:
-
Month
-
Day
Year
Date
Staff Signature:
Date:
-
Month
-
Day
Year
Date
Required Documents Checklist
Photo ID
Insurance Card
Medication List
Proof of Income
Probation/Parole Documentation (if applicable)
Emergency Contact Information
Treatment Discharge Summary (if applicable)
Signed House Rules Agreement
Release of Information Form
Consent for Drug Screening Form
Preview PDF
Submit
Should be Empty: