CLIENT INTAKE FORM

Thank you for choosing Rocky Mountain Sober Living

Rocky Mountain Men's Sober Living homes offer a structured, supportive environment for individuals seeking recovery.  Our goal is to provide an affordable sober living facility to those who want to overcome their addictions and pursue a new, healthier lifestyle—free from alcohol and chemical dependency.  We offer a place to feel human again, establish a disciplined life, and regain and maintain a robust recovery program while experiencing the relational support necessary to sustain a sober existence.

WHAT WE OFFER:

Rocky Mountain Sober Living LLC provides recovery-related activities and access to Coaching Services where individuals can continue working on living skills, developing relationships in the recovery community, and maintaining sobriety while reintegrating into the workforce and community. Members are held to high standards, promoting growth, accountability, and personal development in recovery. 

What you are responsible for: Members provide their own food, hygiene products, clothing, and any personal items they may wish to decorate the rooms with (Must Be Approved By RMSL). Rocky Mountain Sober Living LLC will provide all bedding, pillows, cleaning products, and common household cleaning items.

Residence at Rocky Mountain Sober Living LLC  requires actively working in a recovery program, being a positive member of our community, maintaining abstinence from all drugs and alcohol, and following all house rules, including abiding by curfew requirements.

First name* Client first name - Client last name

Email Address*Client email

Phone Number* Client phone

Date of Birth* Client birthdate

Social Security #: SSN 

Current Personal Address:Client Address

City Client City:

State Client State

Zip Code: Client Zip

Do you have a Valid driver's License or State ID?: Checkboxes

Expiration Date? Date

Current Marital Status* Radio buttons

Number of years married:Text field

Are you currently or have been homeless in the last year?*

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( Program fees are $700/mo if paid in full OR $175/week and one-time intake fees of $150 and $18.90 Processing Fee For Credit Cards)

If You Need a Grant, the Application for the Grant is at the end of this Process.

Are you currently employed?*

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Employer Name? Text field

Employer Phone: Text field

Have you ever been a resident of Rocky Mountain Sober Living before?*

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Have you ever been diagnosed with Bipolar or with schizophrenia?

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In a few sentences, please describe your Mental Health History and current Mental Health situation? *

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Are there any issues (physical or mental) that would prevent you from being able to live in a community living environment?*

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Admission Guidelines: 

• Minimum 18yrs of age 

• Must be sober and able to provide a clean UA/BA upon admission 

• Able to fulfill financial obligations 

• Be able/willing to work, attend school, or volunteer full-time (or any combination thereof) 

• Willing to participate in a 12-step or Recovery program 

• Willing to participate in Rocky Mountain Sober Living LLC’s Program

• You must leave the facility by 8 a.m. and not return until 5 p.m. daily. Unless volunteering 30 hours a week.

I acknowledge I have read and understand all provisions of this agreement:

Printed Name: Text field

Date:Date

Signature:

Signature

Insurance Provider: *Text field

Member ID: *Text field

Group Number: *Text field

Relationship to the Insured Subscriber: *Text field

Medications:

Please BRING ALL MEDICATION BOTTLES, including supplements, to your intake with RMSL.

Knowing the names and dosages of your current medications is VERY IMPORTANT.

Medications:

Please list any medications and dosages you currently take (including over-the-counter medications, herbals, and any nutritional supplements).

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Are You On Medicaly Assisted Treatment? 

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List Any Additional Medications and Dosages here:

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RISK ASSESSMENT (check appropriate boxes): 

1. Have you been in counseling or mental health treatment before? (For example: Counselor, Psychiatrist, Psychologist, Marriage/Family Counselor):*

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2. Have you ever been hospitalized for mental or emotional problems? (For example: nervous breakdown, depression, suicide, mania, Schizophrenia, anxiety, drug or alcohol problems, etc.)*

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3. Has anyone in your family had mental or emotional problems? (For example: nervous breakdown, depression, suicide, mania, drug or alcohol problems, etc)*

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4. Have you ever been referred to Social Services?* 

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5. Been so distressed you seriously wished to end your life? *

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6. Have you had or do you have: 

a. A specific plan for how you would kill yourself? *

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b. Access to weapons/means of hurting yourself? *

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c. Made a serious suicide attempt? *

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d. Purposely done something to hurt yourself? * 

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e. Heard voices telling you to hurt yourself? *  

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7. Had relatives who attempted or committed suicide? * 

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8. Had thoughts of killing or seriously hurting someone? * 

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9. Heard voices telling you to hurt others? *  

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10. Hurt someone or destroyed property on purpose? *  

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11. Slapped, kicked, or punched someone with intent to harm? * 

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12. Been arrested or detained for violent behavior? * 

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12. Been to jail for any reason? *  

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13. Been on probation for any reason? * 

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What do you consider to be the top three stresses in your life?

1. *Text field

2. *Text field

3. *Text field

Mental Health History

1. Have you been in counseling or mental health treatment before? (For example: Counselor, Psychiatrist, Psychologist, Marriage/Family Counselor):*

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2. Have you ever been hospitalized for mental or emotional problems? (For example: nervous breakdown, depression, suicide, mania, Schizophrenia, anxiety, drug or alcohol problems, etc.)*

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3. Has anyone in your family had mental or emotional problems? (For example: nervous breakdown, depression, suicide, mania, drug or alcohol problems, etc)*

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4. Have you ever been referred to Social Services?*

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 Drugs and Alcohol Use:

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6.) Ever had a drink or a drug first thing in the morning?

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Goals for Sober Living:

What are your goals for treatment? In other words, what things would you like to see change or be different about yourself? *

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LEGAL

If you are currently in a program or incarcerated, please describe where, your estimated exit date, and who to contact regarding your application?*

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Please describe your current legal situation?*

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If you are currently on Parole/Probation, please tell us your DOC#Text field

If you are currently on Parole/Probation, please provide us with the county and the name and number of your Parole/Probation officer.*

Name: Text field

County: Text field

Phone Number:Text field

Are you required to register as a sex offender?*

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Have you ever been convicted of felony child abuse or neglect; spousal abuse; a crime against children (including child pornography); or a crime involving violence, including rape, sexual assault, or homicide but not including other types of physical assault or battery?

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Have you ever been convicted of a felony for physical assault, battery, or a drug-related offense within the past five years?

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Have you ever been convicted of arson or arson-related charges?*

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Have you ever been convicted of Murder or Attempted Murder? 

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Membership Fees and Policies. 

Membership Fees:

Member Intake fee: $150.00 Plus Processing Fee of $4.75

Monthly Membership dues: $700.00

Daily Prorated dues: $25.00

Overnight UA Cup: $5.00

*Monthly Processing Fee of $18.90 per month or $4.75 per week. NOTE: Cash Is Not accepted. To Avoid the processing fee, you may pay by Money Order or cashier's Check by the 3rd of each month. After the 3rd, the Processing fee applies regardless of how you pay, either by Money Order, Cashiers Check or Credit or Debit card. 

*All membership dues are Non-Refundable.

*Prices may be subject to change at any time. Members will be notified of any changes.

A non-refundable $150.00 intake fee and any other applicable membership dues are due upon move-in. All Membership dues will be prorated until the end of the calendar month when the member enters the RMSL Membership. Dues may be applied at the discretion of RMSL Staff. If a member is discharged by Rocky Mountain Sober Living LLC or discharged on their own accord at any point, any dues paid will be forfeited. Membership dues will NOT be prorated for the exiting week a member is discharged from the program.

Membership dues will be collected monthly on the 1st of each month. If financial obligations are unmet, the member will be considered non-compliant with Rocky Mountain Sober Living LLC’s program. Once the member is late on his membership fee, his curfew will automatically go to 8 PM or within one-half hour of clocking out or work if the member is, in fact, working nights. Member will be subject to further action, including but not limited to membership probation, non-compliance restriction, and loss of the membership.

Late dues will be applied if the account becomes delinquent. A $25.00 fee will be added the 3rd day after Members' dues are due. Program dues shall not exceed a maximum of 1-week delinquent for any reason. 

Bed reservations may be made in advance before the member moves in. A $150.00 (intake charge) Plus a 2.75% processing fee. Must be paid to secure a bed. This reservation cost is good for NOT more than seven days. This is a non-refundable charge.

I acknowledge all fees paid are final, and no refunds will be given.

*NOTE* Should fees not be paid on time and the account becomes delinquent, immediate restrictions will be imposed. 

Restrictions may be up to and include but are not limited to the following: 

Early curfew, visitor/guest limitations, program probation, and/or program discharge. 

FINANCIAL RESPONSIBILITY AGREEMENT 

All parties who sign this membership agreement acknowledge the responsibility to pay Rocky Mountain Sober Living LLC for all services provided to the above-named member. Members are personally responsible for the charges to this member's account. 

Full balances on this account are due and payable monthly. Membership dues must be made on the first day of each month. Members understand they are paying for the month ahead, not the month behind. Payment arrangements may be made with Rocky Mountain Sober Living LLC staff on a case-by-case basis. However, if you fail to comply with the agreed-upon arrangements, Rocky Mountain Sober Living LLC reserves the right to turn your account to a collection agency. 

I understand that should my account become delinquent, I will be subject to restrictions up to and including, but not limited to, early curfew, visitor/guest limitations, program probation, and cancelation of membership and program discharge. 

Any inquiries or questions regarding your account can be directed to Mike Mattice at (719) 505-3467.

I attest that I have fully read and understand these policies and agree to adhere to the terms within the full agreement.:

Sign: Signature

Date: Date

Phase Program:

 Rocky Mountain Sober Living operates on a phased program. We believe this allows you to be in control of your recovery journey. Below is our phase program and what is required to complete each phase.

*Phase graduation is based on compliance with all rules and regulations of Rocky Mountain Sober Living. You may not phase up without being current on all money owed. 

Blackout Phase:

1-week min. or until you obtain a full-time or volunteer 30 hours AND obtain a coach, therapist, or sponsor. (must verify both)
8 pm Curfew
5 recovery-related activities. *
No overnights,
3 UAs or more per week
2 or more Breathalyzers per week

Phase 1: (30 days)

10 pm curfew
5 recovery-related activities. *
1 overnight per week
2 or more UA’s per week
2 or more Breathalyzers per week

Phase 2: (30 days)

11 pm Curfew
5 recovery-related activities.  *
1 overnight per week
2 or more UA’s per week
2 or more Breathalyzers per week

Phase 3 (30 days)

12 am Curfew
5 recovery-related activities. *
2 overnights per week
2 or more UA’s per week
2 or more Breathalyzers per week.
Phase 1: (30 days)

Transitional Phase: 

12 am curfew
5 recovery-related activities. *
5 Overnights Per Week
2 or more UAs per week
2 or more Breathalyzers per week

Infractions

Minor Infractions will result in the following phase changes:

1st infraction - Start the current phase over

2nd infraction - Move down one phase

3rd infraction - Move to the blackout phase

4th infraction - Termination from the program.

Minor Infractions:

Not signing off and completing the daily chore
Not cleaning up after yourself.
Not making your bed
Miss weekly case management meeting
Late on membership dues.

Major infractions will cause the following phase changes:

1st infraction - Start over at the blackout phase
2nd infraction - Termination of your membership.
Major Infraction
Missing UA

The following will be cause for immediate termination from the program:

Being late for curfew.
Hot or Diluted UA.
Missing Breathalyzer.
Misuse of Medication.
Lying.
Stealing.
Fighting.
Harassment

I have read and understand the Phase Program above. 

Signature. 

Signature

Date:

Date

The Rules:

Sobriety Monitoring: Members are subject to mandatory random urinalysis and breathalyzer screening. Testing will be done at the staff/house manager’s discretion as often as necessary. The member will be given 30 minutes from being asked to produce urinalysis. Upon being asked for a breathalyzer, the member must submit it immediately.  Should the member fail to meet these guidelines or refuse any test, immediate action will be taken, up to and including but not limited to the cancelation of the membership and immediate discharge.

Members can expect to have their belongings checked within the house and any mode of transportation they use. If a search is refused, immediate action will be taken, up to and including but not limited to the cancelation of the membership and immediate discharge.

Physical or verbal abuse, acts or threats of violence, and hostile behaviors WILL NOT be tolerated. Immediate action will be taken, including but not limited to behavioral contracts; immediate action will be taken, up to and including but not limited to the cancelation of the membership and immediate discharge.

Members are NOT permitted to remain on the property if they are found to be under the influence or test positive for any prohibited substance. In the event of a relapse, the situation will be handled case-by-case. Members will be offered a ride to detox or hospital by staff. Staff will not take Members to an unknown/unsafe location. If a member refuses detox/hospital, the member will be allowed 30 minutes (with staff/house manager supervision) to find a ride away from the property. If a ride is not obtained, further action may be taken up to and including, but not limited to, contacting local law enforcement. If a member attempts to operate a vehicle at this time, local law enforcement will be contacted immediately.

Medication-Assisted Treatment (MAT)

RMSL does allow MAT. Your regiment must be doctor-prescribed. Be aware that RMSL does lab tests and monitors your medication levels. If you are a methadone user, you must visit the local clinic to administer your dose. Medications must remain in your locker at all times. Storage of medications anywhere else on the property is grounds for termination from the program.

Rocky Mountain Sober Living LLC does NOT assume any responsibility for lost or stolen medications. Should there be a medication issue, Rocky Mountain Sober Living LLC will investigate the matter as seen fit and WILL NOT reimburse a member for any associated costs. Rocky Mountain Sober Living LLC staff can conduct medication counts anytime. 

Regarding Suboxone, Members on this medication will agree to regular and random medication counts conducted by Rocky Mountain Sober Living LLC staff (or house manager). Should any discrepancy (over or under) occur in the counts, the member will be subject to immediate action, including but not limited to the cancelation of the membership and immediate discharge.

Regarding methadone usage. RMSL requires that you receive your daily dose of Methadone from the local clinic. Storage of Methadone on the site is prohibited.

Personal Property/Money: Rocky Mountain Sober Living LLC does NOT assume any responsibility and will not reimburse any costs associated with lost, stolen, or damaged personal property. It is the member’s responsibility to maintain and protect all personal items. You should keep money and other valuables in your assigned bedside safe.

Rocky Mountain Sober Living LLC staff reserves the right to conduct searches of Members' property at any time, with or without notice. (this includes vehicles). 

*Note* Any personal property left behind once the member is no longer in the Rocky Mountain Sober Living LLC program will be donated and/or discarded after a period of 7 days.

WhatsApp Requirement: I, agree to download WhatsApp; RMSL uses this platform to convey when UAs are due. As well as other important updates. We hope to create a sense of community within each house and RMSL as a whole. The following groups are required to join. House Group, RMSL Main Group, and the Recovery Activity group.

Overnights: Members can take overnights based on their current phase. These can be used one at a time, with 24-hour notice given to the house manager/staff. If more than one overnight is to be used back to back, a minimum of 48 hours notice must be given. Vacations and extended trips must be given at least two weeks' notice to the house manager and will require staff approval. You must request an overnight by scanning the Overnight QR code in the house.

*Note* Members cannot miss any program/house meetings or activities due to an overnight. It is the member’s responsibility to plan/schedule accordingly. Exceptions will be made on a case-by-case basis at staff discretion. If overnights are taken, then there will be a $5 charge for a UA.

Print name:Text field Text field

DOB:Text field

Signature:Signature

Date: Date

Notice of Confidentiality and Willful Agreement of Terms:

I am voluntarily and willfully entering into a membership to participate in a drug/alcohol-free environment of the Rocky Mountain Sober Living LLC program. I agree to maintain and contribute to the safety, accountability, and well-being of the environment at all times. I agree to remain compliant with all previously stated policies. I understand that if I do not remain compliant, my membership will be canceled, I will be discharged from the program, and I will vacate the premises no later than 30 minutes after being asked. 

I understand that I am a member of the Rocky Mountain Sober Living LLC Program and not a tenant of the facility. I waive all my rights as a tenant per Colo. Rev. Stat. 38-12-101 to 38-12-104; 38-12-301 to 38-12- 905; 38-20-102; 13-40-101 to 13-40-123.

I agree to continue working on a recovery program and maintain abstinence from all substances for the duration I am a member of the Rocky Mountain Sober Living LLC program. I agree to maintain and protect the confidentiality of all Rocky Mountain Sober Living LLC program members. I will not admit to any unknown persons the names, locations, or any other relevant information regarding other Members, Rocky Mountain Sober Living LLC locations, or any other business conducted. I will NOT use the address for mail or any other relevant purpose. 

*NOTE* This membership shall become null and void if I become non-compliant with the above-stated policies. Should I refuse to vacate the property, I will be considered trespassing, and law enforcement will be contacted.

Initials: Initials Text field

Communicable Disease Policy

A communicable disease is a disease that can be transmitted from one individual to another via (1) direct physical contact, (2) the air (cough, sneeze or inhaled particle), (3) through a transmission vehicle (either ingested or injected) or (4) through a vector (animals or insects). Examples of some of the most common communicable diseases include measles, influenza, viral hepatitis-A (infectious hepatitis), viral hepatitis-B (serum hepatitis), human immunodeficiency virus (HIV), AIDS, AIDS-related complex (ARC), leprosy, Severe Acute Respiratory Syndrome (SARS) and (COVID-19) and tuberculosis (TB). This definition may be broadened per the recommendations and information from the Centers for Disease Control and Prevention (CDC). Company Name will make decisions involving those with communicable diseases based on medical information concerning the disease in question, the risks of transmission to others, symptoms, and any special circumstances of the individuals involved. The company will weigh potential risks and available alternatives before making any decisions.

Reporting Procedure 

Those Members of RMSL who demonstrate signs or symptoms of a communicable disease that poses a credible threat of transmission to one of the houses of RMSL should report that potential infection or disease immediately to the House Manager, who will inform the owner. The Member is then responsible for keeping informed of conditions requiring extended care, missed work, etc. The Member may also be required to provide written documentation from a physician to return to the Facility.

Intake of Members

RMSL will not discriminate against member applicants with a communicable disease. These individuals will not be denied access to the Facility solely because they have a communicable disease but may be excluded from company facilities, programs, and functions if it is determined that restriction is necessary to protect the welfare of the infected individual or others.RMSL will comply with all applicable statutes that protect the privacy of individuals with communicable diseases. Abuse of this policy will result in disciplinary action up to and including termination. RMSL reserves the right to revise this policy without notice during changing pandemic conditions. 

Name: Text field

Sign: Signature

Date: Date

Miss Representation of any Facts is grounds for immediate cancelation of your Membership and removal from the Rocky Mountain Sober Living Program. 

Name: Text field

Signature: Signature

Date: Date

ADD MED AWR ROI Form

(Release of Information)

Rocky Mountain Sober Living LLC

Member's First Name: Text field

Member's Last Name: Text field

Member's Date of Birth: Date

Member's contact phone number: Text field

Members Social Security Number: SSN

Member:
Please fill this out for any offices, therapists, or person(s) with whom we can communicate regarding your care and/or for request of records.

I authorize the following System of Care User Group Agencies, individuals, or programs as listed below to release Medical Records to Rocky Mountain Sober Living and allow for the exchange of information between parties.

I Authorize the Release of Information *  

For any Emergency, Contact the Listed Below:

You Must Provide at least One Emergency Contact Name:

Emergency Contact Name #1:

Name: Text field

Relationship to patient: Text field

Phone number: Text field

Emergency Contact Name #2

Name: Text field

Relationship to patient: Text field

Phone number: Text field

To Any Law Enforcement Officer or officer of the courts.

To Any Medical Office/Health Professional, EMT, or Rescue Personnel.

I understand that information disclosed may be in written, verbal, or electronic form and may include date(s) of contact, locations, and reasons for contact, symptoms presented, treatment progress, outcome information, prescriptions, written referrals, educational records, medical records, tests performed, and/or diagnosis.

I understand that disclosure may include psychological/psychiatric, medical, shelter and case management, and drug or alcohol use information.

I understand that the purpose of this disclosure is to allow the participating entities identified above to access and use the information to establish and maintain continuity of care, better assess the effectiveness of the program, and/or to improve services based on service utilization studies.

I understand that I may refuse to sign this authorization, and no one is conditioning treatment, payment, enrollment, or eligibility for benefits on signing this authorization.

I understand that there is potential for information disclosed, as a result of this authorization, to be re-disclosed by the recipient and, therefore, no longer protected by the HIPAA Privacy Regulations. When applicable, an assessment of the minimum necessary amount of information required has been applied to this authorization.

I understand that I may revoke this authorization, at any time, by giving written notice to the authorized System of Care User Group agencies or programs, except to the extent that action has already been taken to comply with it. Without such revocation, this authorization will expire on, or if left blank, two years from my signature date.

I understand that I am entitled to a copy of this authorization.

By signing the box below, you are verifying you've read, understand, and agree to all conditions indicated on the Rocky Mountain Sober Living -- ROI (Release of Information) form.

I Consent to ALL of the above. *

Member Signature*
Signature
 
Date of Consent: * 

Date