CROSSROADS OF HOPE SOBER LIVING PRE-ADMISSION INTAKE APPLICATION
Please complete this application accurately and completely. The information provided will be reviewed to help determine eligibility and whether Crossroads of Hope Sober Living can appropriately meet your recovery housing needs. Completion of this application does not guarantee admission.
PERSONAL INFORMATION
Full Legal Name:
First Name
Last Name
Preferred Name:
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age:
Gender:
Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Current Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have a valid photo ID?
Yes
No
EMERGENCY CONTACT
Emergency Contact Name:
First Name
Last Name
Relationship:
Phone Number:
Format: (000) 000-0000.
REFERRAL INFORMATION
How did you hear about Crossroads of Hope?
Self-Referral
Treatment Facility
Recovery Works
Hospital/Healthcare Provider
Probation/Parole
Court/DCS
Case Manager
Peer Recovery Coach
Community Organization
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Next
Family/Friend
Online/Social Media
Other:
Referral Agency/Organization, if applicable:
Referral Contact Name:
Referral Contact Phone:
Format: (000) 000-0000.
Referral Contact Email:
example@example.com
CURRENT LIVING SITUATION
Where are you currently staying?
Treatment Facility
Detox Facility
Hospital
Recovery Residence/Sober Living
Shelter
With Family/Friends
Own Apartment/Home
Unhoused/Homeless
Correctional Facility
Other:
Why are you seeking sober living at this time?
Have you lived in a recovery residence or sober living home before?
Yes
No
If yes, please provide the name of the residence:
Reason for leaving:
SUBSTANCE USE & RECOVERY HISTORY
Primary substance(s) of concern:
Other substances used, if applicable:
Date of last alcohol or substance use:
Substance most recently used:
Current length of sobriety:
Have you experienced an overdose in the past?
Yes
No
If yes, approximately how many?
Have you ever experienced serious withdrawal symptoms?
Yes
No
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Next
If yes, please explain:
Have you ever experienced withdrawal-related seizures, delirium tremens (DTs), or other serious withdrawal complications?
Yes
No
If yes, please explain:
TREATMENT & RECOVERY SERVICES
Are you currently participating in substance use treatment?
Yes
No
If yes, please select:
Residential Treatment
PHP
Intensive Outpatient Program (IOP)
Outpatient Treatment
Individual Therapy
Medication-Assisted Treatment/Medication for Opioid Use Disorder
Other
Current Treatment Provider/Facility:
Expected Discharge Date, if applicable:
Have you previously completed substance use treatment?
Yes
No
If yes, please briefly describe:
Are you willing to participate in recommended recovery services while residing at Crossroads of Hope?
Yes
No
RECOVERY SUPPORT
Do you currently attend recovery support meetings?
Yes
No
If yes, select any that apply:
AA
NA
SMART Recovery
Celebrate Recovery
Faith-Based Recovery
Other
Do you currently have a sponsor, peer recovery coach, or recovery mentor?
Yes
No
Back
Next
No
What are your primary recovery goals?
What do you believe could be a challenge or trigger to maintaining your sobriety?
MEDICAL INFORMATION
Do you have any current medical conditions that may affect your ability to safely live in a recovery residence?
Yes
No
If yes, please explain:
Do you have any allergies?
Yes
No
If yes, please list:
Do you have any physical limitations or accessibility needs?
Yes
No
If yes, please explain:
CURRENT MEDICATIONS
Are you currently taking any prescribed medications?
Yes
No
Medication 1:
Dosage/Frequency:
Medication 2:
Dosage/Frequency:
Medication 3:
Dosage/Frequency:
Medication 4:
Dosage/Frequency:
Additional Medications:
Are you currently prescribed medication as part of substance use disorder treatment?
Yes
No
Buprenorphine/Suboxone
Back
Next
Sublocade
Methadone
Naltrexone/Vivitrol
Other:
Prescribing Provider/Program:
MENTAL & BEHAVIORAL HEALTH
Are you currently receiving mental health services?
Yes
No
If yes, please provide the provider or agency:
Are there any mental or behavioral health needs or accommodations that would be important for us to know when considering your placement?
Yes
No
If yes, please explain:
Have you been hospitalized for a mental or behavioral health concern within the past 12 months?
Yes
No
If yes, please briefly explain:
Are you currently experiencing thoughts of harming yourself or someone else?
Yes
No
LEGAL INFORMATION
Are you currently involved with any of the following?
Probation
Parole
Community Corrections
Drug Court
DCS
Other Court Supervision
None
Probation/Parole/Case Officer, if applicable:
Phone Number:
Format: (000) 000-0000.
Do you have any upcoming court dates?
Yes
No
If yes, please provide the date:
Are you aware of any active warrants?
Yes
No
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Next
Are you currently required to register on a sex offender registry?
Yes
No
Do you have any current legal restrictions that may affect placement in a shared recovery residence?
Yes
No
If yes, please explain:
EMPLOYMENT, EDUCATION & INCOME
Current Employment Status:
Full-Time
Part-Time
Self-Employed
Unemployed
Student
Disability/Benefits
Other
Employer, if applicable:
Work Schedule:
Are you currently attending school or vocational training?
Yes
No
If yes, please provide the school/program:
If you are unemployed, are you willing to seek employment, education, vocational training, or another approved productive activity?
Yes
No
Not Applicable
Current source(s) of income, if applicable:
PAYMENT / FUNDING
How do you anticipate your recovery housing will be funded?
Self-Pay
Recovery Works
SOR/Grant Funding
Family/Support Person
Community Agency
Other
Unsure
If another person or organization will be responsible for payment, please provide their name:
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Next
Are you currently approved for Recovery Works or another recovery housing funding program?
Yes
No
Pending
Unsure
TRANSPORTATION
Do you currently have reliable transportation?
Yes
No
Primary form of transportation:
Personal Vehicle
Public Transportation
Family/Friends
Medical/Program Transportation
Walking/Bicycle
Other:
ACCESSIBILITY & ACCOMMODATIONS
Can you independently complete routine daily living activities such as bathing, dressing, preparing meals, cleaning, and managing your personal belongings?
Yes
No
With Accommodation/Assistance
If you need an accommodation or assistance, please explain:
Are you requesting any reasonable accommodation in order to participate in the recovery residence program?
Yes
No
If yes, please describe:
Are you requesting an accommodation involving a service animal or emotional support animal?
Yes
No
RECOVERY RESIDENCE EXPECTATIONS
Please confirm that you understand the basic expectations of living in a recovery-focused environment.
Are you willing to maintain an alcohol- and illicit drug-free living environment?
Yes
No
Are you willing to participate in drug/alcohol screening in accordance with program policy?
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Next
Are you willing to follow curfew and sign-in/sign-out requirements?
Yes
No
Are you willing to participate in required house meetings and recovery activities?
Yes
No
Are you willing to maintain your personal living area and complete assigned household responsibilities?
Yes
No
Are you willing to treat residents, staff, neighbors, and community members with dignity and respect?
Yes
No
Are you willing to follow Crossroads of Hope Sober Living's resident handbook, house rules, medication policies, safety requirements, and other program policies?
Yes
No
YOUR GOALS
1.
2.
3.
What support would be most helpful to you during your stay?
Is there anything else you would like Crossroads of Hope to know when reviewing your application?
APPLICANT ACKNOWLEDGMENT
I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that submitting this application does not guarantee admission to Crossroads of Hope Sober Living. My application will be reviewed to determine whether the recovery residence can appropriately meet my needs. I understand that Crossroads of Hope may request additional information or documentation before making an admission determination. I understand that if I am accepted, I will be required to review and sign applicable admission documents, resident agreements, policies, acknowledgments, and releases before or at admission.
Applicant Full Name:
First Name
Last Name
Applicant Signature:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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