1. CLIENT INTAKE

CLIENT INTAKE FORM

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.

Please fill out this short application, and we will be in touch with you as soon as possible.

First name* Client first name Last Name* Client last name

Email Address*Client email Phone Number* Client phone

Date of Birth* Client birthdateSocial Security #: SSN 

Personal Address:Client Address

City Client City: State Client StateZip Code: Client Zip

Do you have a Valid Drivers License or State ID #: Dropdown

Social Security Card: Dropdown

Gender* Dropdown

 

What is the best way to contact you?* Dropdown

Which Race or Ethnicity most closely describes you?* Dropdown

Sobriety BirthDate:Date

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Please follow the instructions for each prompt and answer each question thoughtfully. 

Paragraph 1: Tell RMSL about yourself. What led you to substance use? Do you have a history of traumatic events? Please explain.

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Paragraph 2: What is your plan for sober living/recovery residence? How will a recovery residence help you?

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Paragraph 3: Please list 3 goals for your recovery. What steps will you take to complete these goals? How are you working your program (therapy, meetings, groups)? What coping skills do you use?

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Paragraph 4: What are you doing differently or plan to do differently not to fall back into your addiction? 

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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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How did you hear about us, or who referred you?*
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What was the date of your last use, and which substances did you use?*

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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. Is this something that you are willing to do?*

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What is your current source of Funding? ( Program fees are $700/mo if paid in full OR $175/week and one-time intake fee of $150 and $25/mo supply fee)  ***if other support (please specify)* 

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Other*

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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 currently or have been homeless is last year?*

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Have you ever been diagnosed as Bi-Polar 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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Are you required to register as a sex offender?*

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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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Please list ALL medications you are currently taking. (Rocky Mountain Sober Living does not allow any narcotic meds, opiates, or amphetamines. We do allow MAT)*

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Are you on MAT? Please specify

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What type of Health Insurance do you have?*

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Medicaid Number:Text field
Medicare Number:Text field
Tricare Number: Text field

Are you currently employed?*

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

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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 

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

Printed Name: Text field

Date:Date

Signature:

Signature