Application/Intake Form – Life or Death Recovery Services

We are currently accepting applications from men aged 18+. Anyone applying must read the Resident Handbook and submit this completed application prior to interviewing. Upon acceptance, $350.00 intake fee is required prior to move in.  

PERSONAL INFORMATION

Client first nameClient middle nameClient last name

Birthday: Client birthdate

Client phone Client email

Social Security Number: SSN

Marital Status:

Client marital status

Client AddressClient CityClient StateClient Zip

Do you own a vehicle?

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Will you have your vehicle on-site?

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Do you have a valid driver's license?

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RECOVERY INFORMATION

Are you an alcoholic? 

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Are you a drug adict?

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Drug(s) of Choice?

Client substances of choice

 

TreatmentCenterHistory

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Who referred you to Life or Death Recovery Services? 

Client Referred By

Do you attend 12-step meetings?

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Do you have a sponsor?

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SoberLivingHistory

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EMPLOYMENT INFORMATION

Are you currently employed?

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Are you willing/able to get a job within 7 days of moving in?

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Are you willing/able to be self-supporting?

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Will someone else be helping you pay rent or deposit?

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If so, who?

Contact

LEGAL INFORMATION

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Ever been incarcerated?

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Currently on probation/parole? (If yes include name and contact details of your parole officer in the notes below.)

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Probation

Are you a registered sex offender?

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MEDICAL INFORMATION

Select All Medical/ Psychiatric Conditions:

Client health problems

Select All Mental Health Diagnosis:

Client diagnosis

List all Medications:

Medication

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Are you receiving Suboxone, Subutex, Methadone, Vivitrol, etc?

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EMERGENCY CONTACTS (LIST TWO)

Contact #1:

Contact

Contact #1 Phone Number:

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Contact #2:

Contact

Contact #2 Phone Number:

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I have read and agree to all house rules, and I swear every word of this application is true. (signature required)

Signature