Intensive Recovery Application

Welcome to the Sober Homes intake wizard
Click next to begin!


Tell us about yourself

What is your first name?
Client first name
What is your middle name? No middle name? Move on to the next question.
Client middle name
What is your last name?
Client last name
When is your birthdate?
Client birthdate
What is your race/ethnicity?
Client race
What is your Social Security Number
What is your gender?
Client gender
What is your marital status?
Client marital status
Does your spouse support your desire for recovery?
Text field
Do you have any children? If so, how many?
Text field
Are you a veteran?
Client veteran status

Contact Information

How can we reach you?

What is your email address?
Client email
At what phone number can we best reach you at?
Client phone
Street Address:
Client Address
Client City
Client State
Client Zip

Emergency Contact 

Give us a few people that we can reach out to in case of an emergency.

Do you consent for us to communicate with the contacts below?

General Information 

 What is your drug of choice?
Text field
How long have you been using for?
Text field
Do you need to detox? 
Text field
Have you ever been incarcerated?
Are you out on bond, probation, or parole? If yes, please list the officer's contact information.

Medical History

Tell us about your medical history.

Have you been clinically diagnosed with any mental health disorders? Add multiple by clicking in the box and selecting different options
Client diagnosis
Do you have any health problems? Add multiple by clicking in the box and selecting different options
Client health problems
What allergies do you have? No allergies? Move on to the next question.
Client allergies
Do you have any disabilities that will prevent you from using a bunk bed?

Have you had any of the following tests?

Medical Tests


List the medications you are currently prescribed.


Treatment Centers

Tell us about any treatment centers you've previously been admitted into.


Client Referral Source


Who referred you to us?
Client Referred By

 Recovery Commitment 


What date are you looking to admit into the recovery program?
Are you willing to make a 6-month commitment to this program?
Do you agree to random drug tests?
If you have been in recovery before, what makes this time different?

Sober Living History

Tell us about any sober livings you've previously been admitted into.



Tell us about your employment status.
If you're currently unemployed select "unemployed" under "type"


Living Arrangement

Tell us about your living arrangement prior to moving into this facility


 Here at 143 Ministries, we believe in relationships. To get to know you better, we ask that once you have completed this application, please call 1-800-560-7143 Katherine's Way (Female) Ext.1 Immanuel House (Male) Ext. 2.

We look forward to hearing from you and pursuing the recovery journey together.