Please complete this intake form honestly and thoroughly. All information is confidential and used to ensure your safety, eligibility, and a successful experience in our sober living homes.

1. Personal Information
Full Name:Client first name 
Date of Birth Client birthdate
Phone Number:Client phone
Email Address:Client email
Current Address:Client Address, Client City, Client State Client Zip
Gender Identity:Client gender
Preferred Pronouns:Client pronoun
Social Security Number: SSN
Driver’s License or State ID #: Number field
State of Issue:Text field
Emergency Contact Name:Paragraph
Emergency Contact Phone Number:Number field
Relationship to You:Paragraph

2. Recovery Information
Primary Addiction(s):Client substances of choice
Date of Last Use:Date
Current Sobriety Date:Date
Have you completed detox? Dropdown
Are you currently attending any recovery program (AA, NA, SMART Recovery, etc.)? Dropdown
If yes, which one(s)?Paragraph
Do you have a sponsor? Dropdown
Name (if applicable):Paragraph

3. Medical & Mental Health Information
Current Medications (List All):Medication
Do you take prescribed medications for mental health?Dropdown
If yes, explain:Text field
Do you have any medical conditions or disabilities we should know about? Dropdown
If yes, explain:Text field
Have you ever experienced seizures, blackouts, or severe withdrawal? Dropdown
If yes, explain:Paragraph
Do you have any allergies? Dropdown
If yes, list:Medication

4. Legal Information
Are you currently on probation or parole? Dropdown
If yes, provide name and contact info for your PO:Paragraph
Do you have any court requirements for sober living? Dropdown
If yes, please describe:Paragraph
Are you required to attend court dates during your stay?Dropdown
Are there any pending legal issues we should know about?Dropdown

5. Housing & Behavior Agreement
Please initial each statement to acknowledge your understanding and agreement:

Initials Text field I understand this is a drug and alcohol-free home, and any use will result in dismissal.
Initials Text fieldI agree to regular drug and alcohol testing, including urinalysis and breathalyzer tests.
Initials Text fieldI agree to participate in weekly house meetings and recovery activities.
Initials Text fieldI will contribute to house chores and keep my personal and shared spaces clean.
Initials Text fieldI will treat fellow residents and staff with respect and kindness.
Initials Text fieldI understand that violence, threats, or possession of weapons are prohibited.
Initials Text fieldI understand the smoking/vaping policy (outdoors only).
Initials Text fieldI understand and agree to the visitor and pet policy.
Initials Text fieldI agree to pay rent on time, in the amount agreed upon.
Initials Text fieldI understand that failure to follow house rules may result in dismissal from the program.

6. Additional Information 

Are you currently on probation or parole?

Dropdown

Have you attended any treatment centers before? If so, where and when?
 

TreatmentCenterHistory

What is your recent work history or current employment status?

EmploymentHistory

What is the highest level of education you’ve completed?

EducationHistory

Have you lived in a sober living house before? If yes, where and how long?

SoberLivingHistory

ell us about your past recovery experience, including any programs you’ve participated in.

RecoveryHistory

What has your living situation been like over the past year?

LivingArrangementHistory

Do you currently have a therapist or counselor? If yes, please provide their name and contact info.

Therapist/Clinician

What is your current marital status?

Client marital status

How long do you plan to stay in our program?

Client estimated length of stay

What step are you currently working on, if any?

Client step

Are you currently in early recovery, maintenance, or another phase?

Client level/phase

Do you have any criminal history? If yes, please provide a brief overview.

Criminal History

Have you received counseling or therapy before? If yes, when and for what?

Counseling History

Has child welfare or CPS ever been involved in your life? If yes, please explain.

Child Welfare History

Please list your immediate family members and any key support people in your life.

Family Members

 

What are your recovery goals for the next 30 days?

Paragraph
What strengths will you bring to the house community?

Paragraph
Is there anything else you’d like us to know?

Paragraph

Signature & Consent
By signing below, I affirm that the information provided is accurate and complete. I understand the rules and expectations of The Ascent Collective sober living homes and agree to abide by them.

Resident Signature: Signature
Date: Date