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.
*The information provided in this document is strictly confidential and will not be shared/sold, or used for any reason other than that of Rocky Mountain Sober Living LLC’s program and emergency purposes.
Please fill out this short application, and we will contact you soon.
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 driver's License or State ID #: Dropdown Expiration Date? Date
Do you have a Valid Social Security Card or Birth Certificate on your person: Dropdown
Gender* Dropdown
What is the best way to contact you?* Dropdown
Which Race or Ethnicity most closely describes you?* Dropdown
Sobriety BirthDate:Date
EMERGENCY CONTACT:
Contact Name: Text field Contact Phone: Text field
I hereby allow RMSL to contact my Emergency Contact as a reference
_______________________________________________________________________________________________________
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 fees of $150 and $18.90 Processing Fee For Credit Cards) ***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
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.
Initials: Initials Text field
Membership Fees:
Member Intake fee: $150.00
Monthly Membership dues: $700.00
Daily Prorated dues: $25.00
Overnight UA Cup: $5.00
Monthly Processing Fee of 2.75%
*All membership dues are Non-Refundable.
*Prices may be subject to change at any time. Members will be notified of any changes.
*All Fees are Non-Refundable.
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.:
Initials: Initials Text field
*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.
You must leave the facility by 8 am and not return until 5 pm daily. Unless volunteering 30 hours a week.
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 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)
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
Transitional Phase:
12 am curfew
5 recovery-related activities. *
Unlimited overnights
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 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.
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
Initials: Initials Text field
The Rules:
Zero-Tolerance: Rocky Mountain Sober Living LLC has a strict policy regarding the use of drugs and/or alcohol (this includes marijuana or any form of THC Based CBD products, as well as Kratom). Any use of these substances and/or contraband/paraphernalia found on premises will result in immediate action up to and including, but not limited to, non-compliance restriction and/or immediate discharge. Members with knowledge of other Members using and failing to inform staff will be subject to the same/similar action.
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.
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 mins from being asked to produce urinalysis. Upon being asked for a breathalyzer, the member must submit it immediately. “False Positive” test results will NOT be accepted. 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.
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 mins (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.
Medications: If a member is taking any medications (prescription or over the counter), these will be REQUIRED to be kept in their personal bedside safe that is located onsite at all times. Under no circumstances may a member share or distribute their medications to any other member. Medications must remain in your safe at all times. Storage of medications anywhere else on the property grounds for termination of the client's membership.
Medication-Assisted Treatment (MAT)
RMSL does allow MAT. Your regiment must be Dr 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 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.
Initials: Initials Text field
House Meetings/Case Management: Members are required to attend MANDATORY house business meetings. The day and time of the House meeting will be at the house manager's discretion. Should a member need to miss these meetings for any reason, the notification must be given to staff no less than 48 hours prior and must be given approval.
Weekly House Peer Support Meetings: These are not mandatory. The members can also expect to meet with a peer support specialist once a week. The day and time of the House meeting will be at the house manager's discretion. These meetings will cover recovery-related topics as well as weekly check-ins.
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.
Initials: Initials Text field
Personal Vehicles: Members can only have one vehicle on the RMSL property. If, for any reason, the Vehicle becomes inoperable, it must be removed from the property within 72 hours. If not removed, it will be towed at the owner's expense.
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Employment/Volunteering: The member must obtain and maintain active employment, volunteer, attend school, or any combination thereof within two weeks of admittance. And these must consist of a minimum of 30 hours per week. If not working or volunteering Full time, the member must leave the facility between 8 am and 5 pm. They may return for daily lunch for no longer than 30 minutes. The member must remember obligations to attend house meetings, case management, and recovery meetings and balance their work schedule with program obligations. Members must provide proof of hours worked for the first four weeks. Additional requirements may be required on a case-by-case basis.
Initials: Initials Text field
Recovery Participation Defined: Joni and Mike want you to pursue any of the 12-step programs that suit you. Members are required to be working on their recovery. This is achieved by doing five recovery-related activities per week for your stay. You can achieve this in many ways, 12-step in-person meetings, Smart Recovery, Celebrate Recovery, Darma, Going to the Phoenix gym, Professional Therapy, and Peer Coaching; the weekly peer support group at the RMSL counts as one activity. RMSL understands that there are many paths to recovery. We expect your active participation in your recovery. If you are not working on a program, your membership will be canceled and removed from the RMSL program. Please note that Zoom 12-step meetings do not count toward recovery-related activities.
Initials: Initials Text field
Peer Recovery Coaching & Case Management: Rocky Mountain Sober Living has partnered with Various Organizations to provide our members with free and free peer coaching and case mangement. Upon being admitted to RMSL, Members will be assigned a case manager/peer coach with an agency that RMSL is aligned. Members will meet with case management weekly to help assist with any needs or resources Members will need. Members must meet with their peer coach weekly to work on recovery. We believe a big part of one's success is for Members to have as much support and resources as possible.
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 24hrs 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.
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Guests: All guests are allowed in the common areas of the house ONLY. This includes living rooms, garages, front/back yards, restrooms, and smoking areas. Guests are NOT allowed in bedrooms for any reason. Guests are to be out of the house and off the property by 9 pm on weekdays and 10 pm on weekdays, with No Exceptions. Guests MUST be sober to visit or be on the property. Rocky Mountain Sober Living LLC reserves the right to subject guests to a UA/BA test if they are suspected to be under the influence of any substance. If a guest is found to be under the influence or if the guest refuses to submit to a test, the guest will be required to vacate the property immediately:
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Fraternization: There is ZERO TOLERANCE for fraternization and/or sexual activity in the house or on Rocky Mountain Sober Living LLC property. If a member is caught engaging in these behaviors, action up to and including, but not limited to, non-compliance contract, restrictions, and/or immediate discharge will be taken.
Cleanliness/Chores: Members are expected to maintain a clean environment. This includes making your bed at the start of each day and cleaning your room, and you will be assigned a house chore that is expected to be completed daily. There will be random inspections, and there will also be a monthly deep clean on the first Sunday of each month.
Rocky Mountain Sober Living LLC Property: Rocky Mountain Sober Living LLC Property: All property must be treated respectfully. Any damage caused to Rocky Mountain Sober Living LLC property will become the financial responsibility of the individual responsible. ANY theft of Rocky Mountain, Sober Living LLC property, will result in immediate action up to and including, but not limited to, immediate discharge and/or law enforcement being contacted.
Smoking: There is NO smoking in the house. There is a designated smoking area in the rear of the house. All smoking should be kept in this area only. There are also designated cigarette disposal receptacles. Cigarette butts and trash MUST be picked up and kept clean. If a member is caught smoking in the house, their membership will be canceled, and they will be discharged immediately.
Pets: No pets are allowed in the home at any time. If a guest brings a family pet or animal to visit, pets may be allowed in the yards ONLY, and the member MUST clean up after the animals immediately.
Portable/Space Heaters: Portable heaters are prohibited in the home/bedrooms.
Weapons/Firearms: At no time are weapons or firearms permitted to be on or around Rocky Mountain Sober Living LLC property. This includes vehicles. Prohibited weapons include but are not limited to swords, butterfly knives, switchblade knives, brass knuckles, guns of any type, and archery bows/arrows. Failure to comply with this may result in action up to and including, but not limited to, immediate discharge or contacting law enforcement.
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Program Discharge: If a member fails to comply with any of the above-stated policies, actions up to and including, but not limited to, immediate discharge may be taken. During program discharge, the member will be given 30 minutes to collect all personal belongings and vacate Rocky Mountain Sober Living LLC property. Any belongings not collected in these 30 minutes will need to be collected later, which MUST be scheduled with staff within 72 hours.
Initials: Initials Text field
Consent To Background Check: I hereby authorize Rocky Mountain Sober Living LLC of 1716 E Yampa St, Colorado Springs, CO 80909, and/or its agents to make an investigation of my background, references, character, past employment, consumer reports, education, and criminal history record information which may be in any state or local files, including those maintained by both public and private organizations, and all public records, to confirm the information contained on my application and/or obtain other information which may be material to my qualifications for acceptance into the RMSL program. A telephone facsimile (fax) or xerographic copy of this consent shall be considered valid as the original consent.
Print name:Client first name Client last nameDOB:Client birthdate
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.
Initials:Initials Text field
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.
Sign:Signature
Date:Date