APPLICATION:

General

If you are currently experiencing a psychiatric or medical emergency, please call 911 or visit your local emergency room. 

First Name:

Middle Name:

Last Name:

Address: 

City: 

Email: 

Gender:

School: 

Marital status: 

Race: 

Veteran: 

Desired Move in Date: 

What is your sober date:

Please list a few activities or hobbies you enjoy doing: 

Do you have any concerns about living with roommates: 

If Yes, please explain: 

Do you currently work, go to school, or volunteer? 

If Yes, please provide information about Name, Where, Your schedule, etc. If No, please provide information about your current situation:

Emergency Contact

Medical History

Diagnosis: 

Do you have any special medical equipment you would need to bring with you?

If yes, please provide details:  

Medications: 

Are you currently in a treatment program for substance abuse or behavioral health? 

If Yes, please provide details of your program below -

Name of Program: 

Case Manager, Counselor, or Therapist Name: 

Case Manager, Counselor, or Therapist Contact Information: 

Condition being treated for: 

Please be advised: 

Acceptable and properly prescribed medication, like MAT (medication assisted treatment) prescriptions are permitted on the premise of Lemonade Recovery Homes. Lemonade Recovery Homes is not a medical facility and in accordance with the State of California regulations will not administer any medication to residents of Lemonade Recovery Homes.

All residents are responsible for the proper storage and self- administration of their own medication(s). 

Accessability

Can you walk independently? 

If no or sometimes, please explain: 

Can you bath and dress yourself? 

If No or Sometimes Explain:

Do you have any issues with bladder control? 

If Yes or Sometimes Explain: 

All applicants must be able to engage independently in major life activities including eating, dressing, bathing and other activities consistent with independent living. Please describe any concerns you may have regarding independent living, if applicable.

History of Substance Use

Substance of Choice: 

Kinds of meetings attended: 

Number of meetings attended each week: 

Allergies: 

Referral source:

Licence number

Other History

Do you have a criminal record? 

Are you on probation? 

Insurance Information:

Health Insurance: 

Health Insurance Policy

Provider: 

Group ID: 

Address:(Street) (City) (State) (Zip)

 Financial Information

Are you receiving welfare, unemployment compensation, disability payments, workman’s comp, alimony, VA benefits, or other income?

Explain: 

Intake Coordinator notes: