6o3 Sober Living Intake
6o3 Sober Living is a 4-phased Sober Living Recovery Program; where residents will build their foundation on sobriety, work a program of recovery, and gain support through their local community. We are a faith-based Sober Living, and provide access to engage in Faith-Based Recovery; 12-Step Recovery; and various other forms of Recovery. Within the first 7-days of your stay in our sober house, the Leadership team will review your required recovery program and set you up for success!
6o3 Sober Living does accept Medication Assisted Treatment and abstinent based sobriety, as well. Medications will be locked in a specific resident only combination lock box, and placed in a locked cabinet located in our locked medication/supply room. Medications will be observed by Leadership upon taking.
Weekly Program Fee is $225. Intake and Criminal Background Fee is $150. Weekly Program Fee is due by Sunday at 6pm. Weekly Program Fee includes: Heat/Electric/WIFI/Netflix/Disney+/Case Management Service.
We do accept funding through Southern NH Services; Community Action Partners, NHCORR, The Doorway, and the Herron Project.
Unfortunately, we cannot accept residents with violent major crimes such as sexual offenses, arson and some domestic violence. Please fill out the criminal record section and we will discuss together. A criminal background will still be run, prior to acceptance of your application and move in date.
We also take into consideration all reasonable accommodations. During your phone intake, this will be discussed at length. You may be asked to complete a formalized Reasonable Accommodation Form upon acceptance.
Click next to begin!
General
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 gender?
Client gender
What is your marital status?
Client marital status
Do you have any children?
Dropdown
Tell us a little about your children. Are you able to see them? Do you have custodial rights? Any other information you'd like to share.
Paragraph
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
Last Known Street Address:
Client Address
City:
Client City
State:
Client State
Zipcode:
Client Zip
Emergency Contacts
Give us a few people that we can reach out to in case of an emergency.
Contact
Insurance
Enter your insurance provider(s). We do not accept or require you to have insurance. We will assist you in obtaining insurance, if needed.
Insurances
Medical History
Tell us about your medical history.
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
Last known physical?
Date
Do you have a Primary Care Physician?
Dropdown
How often do you see your Primary Care Physician?
Text field
Have you had any of the following tests?
Medical Tests
Medications
List the medications you are currently prescribed.
Medication
Treatment Centers
Tell us about any treatment centers you've previously been admitted into.
TreatmentCenterHistory
Do you have a Case Manager? Checkboxes
Name of Case Manager: Text field
Contact number for Case Manager: Text field
What is your sobriety date?
Date
Are you currently on Medication Assisted Treatment?
Dropdown
What type of Medication Assisted Treatment are you prescribed?
Text field
Do you have plans to taper your Medication Assisted Treatment?
Dropdown
When will you begin to taper?
Date
What is your substance(s) of choice? Add multiple by clicking in the box and selecting different options.
Client substances of choice
How many meetings in a week do you attend?
Text field
Do you have a sponsor or recovery coach?
Text field
Sober Living History
Tell us about any sober livings you've previously been admitted into.
SoberLivingHistory
Employment
Tell us about your employment status.
If you're currently unemployed select "unemployed" under "type"
EmploymentHistory
Living Arrangement
Tell us about your living arrangement prior to moving into this facility
LivingArrangementHistory
Mental Health Information
Tell us briefly about any Mental Health information you might have.
Have you been clinically diagnosed with a mental health disorder? Dropdown
If yes, what have you been diagnosed with? Text field
Are you in Mental Health Counseling? Dropdown
If yes, how often do you attend Mental Health Counseling? Text field
Criminal History
Please provide us a brief criminal history. 6o3 Sober Living prides itself for working with individuals in the criminal justice system. We, however, cannot accept anyone who has a violant criminal past such as Arson, or sexual offenses and some domestic violance. Please contact us if your criminal history falls into these categories. We will discuss options and make referrals, if needed.
Do you have any criminal pending charges at this time? Dropdown
If yes, what is your pending charge(s)? Text field
If yes, when is your next court date? Date
Most recent criminal charge? Text field
Are you currently on probation? Dropdown
Referral Source
Who referred you to 6o3 Sober Living? Text field
Thank you for your application. We will be in touch; to let you know we received your application and discuss next steps. If you have any questions, please call us at 603-660-0843.