Under HIS Construction – New Resident Application & Intake Form

Under HIS Construction – New Resident Application & Intake Form

Please complete this respectful and confidential application so we can learn about your background, needs, goals, and readiness for admission to Under HIS Construction. Review each page carefully, use None or Not applicable where appropriate, and complete the required acknowledgments and signature at the end.
Applicant Contact and Personal Information
Full Legal Name

First NameMiddle NameLast Name
Preferred Name / Nickname
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Gender Identity
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Current Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Mailing Address (if different)

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Preferred Contact Method
Additional Demographic Notes
Emergency Contact
Emergency Contact Full Name

First NameMiddle NameLast Name
Relationship to Applicant
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
May this contact be reached in an emergency?
Identification and ID Upload
Type of Government-Issued ID
ID Number
Issuing State or Country
ID Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Government ID Upload

Cancelof
Recovery and Substance-Use History
Are you currently using any substances or alcohol?
Which substances have you used in the past or are you using now?

Other
Date of last use

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
How often do you use these substances?
How are substances typically used?

Other
Age at first use
Have you ever had a period of recovery or sobriety?
Please describe any past recovery periods or sober living experiences
How many previous treatment episodes have you had?
What types of treatment or recovery support have you received?

Other
Have you experienced relapse after a period of recovery?
If yes, briefly describe relapse history and any common triggers
Do you currently experience cravings?
If yes, describe current cravings or triggers
Additional details about substance-use history
Medical History, Allergies, Medications, Providers, Pharmacy, and Medical Needs
Current medical conditions

Other
Details about current medical conditions
Past significant medical conditions or surgeries/hospitalizations
Allergies

Other
Allergy item(s)
Reaction or symptoms
Current medications
Upload medication list or related documents if applicable

Cancelof
Primary care provider
Specialists or other medical providers
Preferred pharmacy
Ongoing medical needs or treatments
Mobility or assistive-device needs

Other
Special accommodations needed
Mental and Behavioral-Health Information
Have you ever been diagnosed with any mental or behavioral health condition?

Other
Have you ever received counseling, therapy, or mental health services?

Other
Please describe your counseling or therapy history, including approximate dates, frequency, and outcomes.
If yes, please list the approximate dates, facility names, and reasons for hospitalization.
Are you currently receiving mental-health treatment?
Current mental-health provider or clinician name
Current mental-health provider or clinician phone number
Please enter a valid phone number.Format: (000) 000-0000.
List any medications you are currently taking for mental or emotional health, or indicate None.
Have you ever had thoughts of self-harm or suicide?
If yes, please describe any safety supports, crisis plans, or current coping strategies that help you stay safe.
Please share any trauma history only if you choose to disclose, and any coping supports you currently rely on.
Safety and Emergency Information
Do you have any current safety concerns?
If yes, please describe your current safety concerns
Have you ever had thoughts of harming yourself or others?
If yes, please describe the history and whether there is any current risk
Have you recently experienced abuse, violence, coercion, or an unsafe living environment?
If yes, please describe the situation and any immediate safety needs
Do you have any urgent medical or safety conditions the staff should know about?

Other
Please list any emergency instructions, warning signs, or preferences staff should follow
Legal, Probation/Parole, Court Requirements, and Document Uploads
Are you currently on probation or parole?
Probation or parole officer name
Probation or parole officer phone number
Please enter a valid phone number.Format: (000) 000-0000.
Court dates, requirements, or upcoming legal obligations
Upload court, probation, or legal documents

Cancelof
Employment, Transportation, and Financial Information
Employment Status

Other
Employer Name
Occupation or Job Title
Work Schedule
Primary Income Source

Other
Transportation Access

Other
Driver’s License Status
Vehicle Access
Current Financial Concerns

Other
Employment, Transportation, or Financial Support Needs
Family and Support System
Marital status
Do you have any children or dependents?
Children or dependents
People currently involved in your support system
Support people and contact details
Is there an emergency family contact different from the main emergency contact?
Emergency family contact details
Positive supports in your life
Strained or difficult family relationships
Would you like family involvement in your recovery plan?
Christian Faith and Spiritual Life
Current faith affiliation
How would you describe your relationship with God or your spiritual life?
How often do you attend church or faith services?
Which spiritual practices are part of your life?

Other
How comfortable are you with Christian-based programming?
Which of the following Christian-based activities would you be willing to participate in?

Other
Please describe any concerns, boundaries, or needs related to faith-based recovery programming
If you have little or no Christian background, please share any traditions, beliefs, or support practices that are important to you
Is there anything else you would like us to know about your faith or spiritual life?
Recovery Goals and Readiness for a Recovery Home
What are your main goals for recovery while living in a recovery home?
Why are you seeking admission to a recovery home at this time?
How ready are you to be accountable to house rules, schedules, and expectations?
If you selected Unsure or Not ready yet, please explain any concerns or barriers.
Are you willing to follow the structure and rules of a recovery home?
What is your understanding of community living in a shared recovery environment?
Are you willing and able to commit to the 1-year term of this program?
Describe your personal goals for sobriety, stability, and growth during your stay.
Current Housing Situation
Preferred Admission / Move-In Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Primary Language
Do you have any restrictions or limitations we should know about?
Do you have any legal restrictions that affect program participation?
Do you have a history of violence or aggression toward others?
Program Rules, Policies, Consents, and Acknowledgments
Open the handbook PDF
HIPAA Notice
Privacy Policy
Substance-Use Confidentiality Notice
Acknowledgment of Program Rules and House Policies

Other
Confidentiality and Information Sharing Acknowledgment

Other
Consent for Program Participation Terms

Other
Acknowledgment of Release and Authorization Terms

Other
Applicant Agreement and Acknowledgment Signature
Final Certification and Electronic Signature
Final certification and attestation

I certify that the information provided is true, complete, and accurate to the best of my knowledge. I understand that any false or omitted information may affect my application. I consent to be considered for admission to the recovery home and agree to honor its Christian values, program expectations, and house guidelines if accepted. I acknowledge that submission of this form does not guarantee acceptance. I commit to seeking growth, accountability, and healing through God’s guidance.
Typed name of applicant

First NameMiddle NameLast Name
Electronic signature
Date of certification

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Under HIS Construction – New Resident Application & Intake Form

Applicant Contact and Personal Information

Emergency Contact

Identification and ID Upload

Recovery and Substance-Use History

Medical History, Allergies, Medications, Providers, Pharmacy, and Medical Needs

Mental and Behavioral-Health Information

Safety and Emergency Information

Legal, Probation/Parole, Court Requirements, and Document Uploads

Employment, Transportation, and Financial Information

Family and Support System

Christian Faith and Spiritual Life

Recovery Goals and Readiness for a Recovery Home

Program Rules, Policies, Consents, and Acknowledgments

Final Certification and Electronic Signature