Sober Living Intake Form

Gemstone Housing Network

Providing specialized supportive housing pathways designed to meet the unique needs of individuals experiencing recovery challenges, reentry barriers, disabilities, and life transitions.
Mighty Success Recovery Inc. Gemstone Housing Network

Quartz House — Clarity, stability, foundation: sober living housing for individuals building recovery, accountability, and independence.
Onyx House — Protection, strength, resilience: halfway housing / reentry support for individuals transitioning from incarceration back into the community.
Amethyst House — Calm, healing, balance: behavioral health and recovery support housing for individuals needing structured support, wellness planning, and recovery services.
Emerald House — Renewal, growth, restoration: young adult housing supporting life skills, education, employment, and independence.
Sapphire House — Wisdom, confidence, protection: disabled person supportive housing with connections to disability resources and supportive services.
Diamond House — Strength, endurance, transformation: vision-impaired and accessibility housing designed around independence and assistive support needs.
Ruby House — Courage, accountability, determination: justice-involved offender supportive housing focused on accountability, community safety, reentry planning, and successful reintegration.
Resident Intake & Supportive Housing Assessment
For safety and privacy, addresses are only shared with approved residents, social workers, probation or parole officers, or medical professionals.
Preferred house waiting list
Full Name

First NameMiddle NameLast Name
Preferred Name
Applicant Information
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Social Network Handle
Emergency Contact Name

First NameMiddle NameLast Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relationship
Preferred Contact Method
Current Address or City/Zip Code

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Current Living Situation
Assessment
Tell us about yourself
What are your strengths and goals?
Who is in your support system?
Tell us about your family and community connections
Do you have transportation?
Do you have a spouse, children, or pets?
Primary Substance
Health Insurance Provider (if applicable)
Do you smoke cigarettes, vape, or alcohol?
Current employment status
Education or training background
Do you plan to enroll in a trade or other educational program?
Transportation needs
Recovery Background
Recovery goals
Length of sobriety (if applicable)
Recovery supports

Other
Treatment history
Current support providers
Housing Needs
Reason for Seeking Placement
Current Housing Situation
Desired Move-in Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Current Legal Status Details
Do you have any current physical or mental health concerns?
Are you currently receiving counseling, therapy, or treatment?
How will program fees be covered?

Other
Primary Income Source
Is there anything else we should know to support your recovery and housing placement?
Can You Contribute Toward Housing Costs?
Reentry Assessment
Are you returning to the community after being incarcerated?
Current supervision requirement
Probation or parole contact information (if applicable)
Reentry goals
Behavioral & Support Needs
What types of support do you need?

Other
Please describe any disability accommodations you need
Please describe any medication support needs
Please describe any accessibility needs
Volunteer and Resident Participation Opportunities
Mighty Success Recovery Inc. welcomes individuals who are interested in volunteering and supporting our mission. Volunteer opportunities may include assisting with community activities, program support, administrative tasks, property upkeep projects, outreach activities, and other approved service activities. Volunteer participation is optional and is not considered employment. Volunteers do not receive wages or compensation for their service. Residents may be encouraged to participate in community responsibilities, life skills activities, and program engagement opportunities that promote accountability, independence, and successful housing outcomes. Any resident financial assistance, scholarships, or reduced program fees are determined separately based on program guidelines and available resources.
Program Agreement
Housing placement is currently limited at Gemstone Housing.
House Expectations Acknowledgement
Program Commitments

Other
Applicant Signature
Date Signed

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

Gemstone Housing Network

Resident Intake & Supportive Housing Assessment

Applicant Information

Assessment

Recovery Background

Housing Needs

Reentry Assessment

Behavioral & Support Needs

Volunteer and Resident Participation Opportunities

Program Agreement