DEMO Homes: New Resident Screening Packet
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First:
Client first name
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Middle:
Client middle name
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Last:
Client last name
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Birthdate:
Client birthdate
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Phone:
Client phone
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Insurance:
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Ethnicity:
Client ethnicity
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Gender:
Client gender
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Email:
Client email
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DISCRIMINATION NOTICE: DEMO Homes does not discriminate based on age, race, gender, medical condition or
sexuality. This packet is for informational and recording purposes and will not be shared or sold to outside entities.
DEMO Homes provides an atmosphere that supports independence and rehabilitation towards recovery for individuals who have been sober for at least 30 days. After-care services will be provided to include continued support with partnered behavioral health agencies and case management services to assist in maintaining sobriety and promoting wellness and overall self-care. DEMO Homes requires a 90-day minimum commitment from all residents. All residents will be required to attend 12-step meetings and have an active sponsor. Residents will also be required to either volunteer, attend school, or work (part-time/full-time).
The DEMO Homes Referral is a screening process for future house members. This is not a lease, application, or approval of acceptance into the residence or program. All information provided should be answered to the best of your ability; there is no commitment in result of the completion of this document. A phone interview with client will be scheduled upon receipt of packet.
*Note: A deposit equal to one weeks rent, plus the first weeks rent, will be required at the time of move-in.
How did you hear about us?
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EMPLOYMENT INFORMATION
Are you employed?:
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If yes,
Weekly hours worked: Text field
Weekly Income: Text field
Employment income: Dropdown
Employer: Text field
Employer Phone: Text field
TREATMENT QUESTIONNAIRE
Have you ever overdosed?:
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If yes, how many times?: Text field
How many treatments/detox centers have you’ve been admitted to?: Text field
How many have you completed?: Text field
What is your drug of choice?: Text field
How long have you been using your drug of choice?: Text field
What is the longest time you’ve maintain sobriety?: Text field
Currently, how long have you been completely abstinent from drugs andalcohol?: Text field
Do you attend AA/NA Meetings?
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Do you have a Sponsor?
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Have you ever completed all 12 steps?:
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Do you believe you have an addiction?
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Are you currently taking any Medical Physician prescribed medications?
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Have you ever received counseling services?
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Are you receiving Medication Assistance Treatment (MAT) for substance abuse?
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GOALS
What goals do you want to achieve by living in DEMO Homes Sober Living? Please list at least two (2)?
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Identify your specific barriers to recovery. Please list at least one (1).
Are you under Mandatory Criminal Probation/Patrol?
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If Yes, Please provide details:
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DEMO Homes Program Checklist
(Please Check All That Apply)
I am ready to live a healthy life.
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I believe recovery is possible.
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I understand the recovery process may be difficult and challenging. I will commit to being honest with myself, staff and fellow program participants. If I feel like relapsing, not taking prescribed medications, giving up or quitting, I will accept truth and guidance from my established and identified support system.
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I understand that part of positive and healthy growth involves the DEMO Homes staff holding me accountable to my goals and healthy behaviors.
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I have read and understand the guidelines of the program and my responsibility as a client of the DEMO Homes Sober Living program. If anything was mentioned in this screening process that I do not understand, it was explained effectively.
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I am ready for change!
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Let’s review your responses. If all boxes are checked, DEMO Homes could be the appropriate place for you and we would love for you to continue with the program’s screening process. If there are any boxes unchecked, DEMO Homes may not be the best program to fit your current needs. Please don’t be discouraged. You are welcome to participate in the screening process at another time.
Written Agreement for Screening
I hereby declare that the information I have provided is true and correct to the best of my knowledge. I understand that DEMO Homes is a zero-tolerance sober living environment and in order to continue residency, I must remain sober for the entire duration of my stay. I understand and will comply with the requirement to participate in the DEMO Homes Sober Living community 12-step group session as a part of the recovery process. Failure to comply with the rules of the house will result in the termination of my stay at DEMO Homes and no refunds of payment will be provided. I understand that I am in control of my recovery and will accept positive guidance to reach my goals.
1. I acknowledge and agree that as a member of the DEMO Homes Sober Living community, I must agree to a minimum commitment of a three (3) month stay.
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2. No house member will be admitted with a history of sexual assault charges or convictions. All applicants are subject to a background check prior to being accepted as a client of DEMO Homes.
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3. All house members understand they are NOT tenants of DEMO Homes, but rather guests in our home. I agree that I am not protected by, nor will I invoke any protections of local landlord tenant laws. If it is found that local landlord tenant law applies, I hereby renounce any rights that I may or may not have relating to same.
Initials Text field
*Proposed move-in date?: Date