Sober Living Non-Medical Assessment Form
Complete this non-medical assessment to help us understand your needs and fit for the program.
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Age
*
Current Living Situation
*
Living with family
Living alone
Temporary housing
Homeless
Other
Reason for Seeking Our Home Living
*
Have you lived in a independent living home before?
*
Yes
No
If yes, please briefly describe your experience.
Do you have a support system (family, friends, sponsor, etc.)?
*
Yes
No
What are your goals while living in one of our homes?
*
Physicians Name
Number
Emergency Contact
Number
Current Living Situation
Any Recent Hospitalizations or Medical Issues
Height and Weight
List All Current Medications
Need Palliative Care
Dental Issues
Vision Issues
Hearing
Type a question
Mental Health Status (Click all that apply)
Alert
Oriented
Confused
Disoriented
Memory Issues
Smoking Habit
Heavy
Medium
Light
None Smoker
Any Special Diet Requirements
Any Allergies
Primary Language Spoken
Any Communication Issues
Any Speech Issues
Any Fuctional Limitations
Any Mobility Issues
Ambulation Issues
Any Issues Bathing Yourself
Type a question
Any Issues Dressing Yourself
Any Issues Grooming and Maintaning your Hygiene
Can You Prepare and Feed Yourself
Do You Have Contol Of Your Bladder
Do You Have Control Of Your Bowels
Exercise Frequency
Can You Clean Up After Yourself
Can You Shop For Yourself
Are You Able To Drive Yourself
Are You Able To Use A Cell Phone
Do You Needf Any Type Of Attendant
Is Your Current Living Condition Adequate
Any Safety / Health Hazards
Living Companions
Alone
With Spouse / Partner
With Adult Child
Other Adult Male
Other Adult Female
Signature
Submit Assessment
Submit Assessment
Should be Empty: