Self-Disclosure Intake Application Packet
Tucson Recovery Homes provides individual recovery support services and sober living. We assist with recovery and other related life and wellness goals. Please understand it can be difficult or can take longer to support you when you are not honest with us. The information you provide will help us to determine the best fit for recovery support services. Please consider this when filling out your packet. Your trusted information is completely confidential.
PERSONAL INFORMATION
Today’s Date:Date
Your Name: Client first name Client last nameClient nickname
Date of Birth:Client birthdate
Age: Number field
Marital Status: Dropdown
Gender: Client gender
Pronouns: Client pronoun
Driver’s License / ID Card: #Text field
State Issued:Text field
Exp:Date
SSN: SSN
Email: Client email
Cell Phone: Client phone
Ethnic or Religious preferences: Text field
Are you pregnant: Dropdown
Are you a Veteran: Client veteran status
Home Address: Client Address
City Client City
State Client State
Zip Code Client Zip
In case of an emergency who should we notify:
An emergency in this situation is described as 1.) an illness, injury or death requiring medical or legal intervention 2.) Appearing to be incapable of handling financial affairs or 3.) Non-compliance with Participant Agreement.
Contact
LIST ANY ALLERGIES Client allergies
Requested Move In Date:Date
Referral Reference Name: Text field Email:Text field
Agency or Company: Text field Phone: Number field
RECOVERY HISTORY
Are you seeking support for an Addiction or Mental Health history or both (what are you recovering from) Paragraph
What is your recovery date: Date
List names and dates of Residential, PHP or IOP Treatment programs attended in the past: TreatmentCenterHistory
How many attempts have you made at recovery in the past? Number field
What is the most time in recovery you have attained in the past? Text field
Have you ever attended self-help support groups? Dropdown
Which ones? Text field
Longest period of time you attended? Text field
Why did you stop going? Text field
RECOVERY SUPPORT
Are you willing to follow Sponsor / Mentor recommendations to sustain your recovery if they see changes need to be made? Text field
Are you willing to attend outside scheduled clinical team and/or Recovery support meetings and follow your team’s personal recommendations to sustain your recovery? Text field
Are you attending any services or programs right now to support your continued growth? Text field
Do you currently have any personal community supports? Dropdown
If Yes, please explain: Text field
EDUCATION HISTORY
Dropdown
Other Text field
Do you plan to continue your education? Dropdown
Where and when? Text field
SUBSTANCE ABUSE HISTORY
Client substances of choice
What age did you first use substances of any kind? Number field
How often did you use substances? Dropdown
What is the last date you used?Date
Route of use? List ALL
DropdownDropdownDropdownDropdownDropdown
MENTAL HEALTH HISTORY (Includes SUD)
Please select all current diagnosis
Client diagnosis
Age first diagnosed Number field
List all Medications for Diagnosis and the DOSE
Medication
PSYCHIATRIC HISTORY
Please list any recent times you have needed the help of a psychiatric facility:
Date Date
Reason Text field
Location Text field
Length of Stay Text field
Date Date
Reason Text field
Location Text field
Length of Stay Text field
Date Date
Reason Text field
Location Text field
Length of Stay Text field
Are you currently working with a behavior health provider:Dropdown
For How long? Text field Agency Name Text field
Have you ever attempted suicide? Dropdown
If yes, approximate dates: Text field
Circumstances: Text field
Are you suicidal now?Dropdown
MEDICAL HISTORY
Are you under a physician’s care?Dropdown
If yes, why? Text field
Dr. Name: Text field Phone: Number field
Agency or Practice Name:Text field
List all current and past physical medical health concerns:
Concern: Text field Current Checkboxes
Concern: Text field Current Checkboxes
Concern: Text field Current Checkboxes
Concern: Text field Current Checkboxes
EMPLOYMENT HISTORY
EmploymentHistory
OTHER EMPLOYMENT QUESTIONS
If you are working, are you willing to follow your team’s recommendation regarding working if they see changes that need to be made?Dropdown
If you are not working, is it your goal to become employed? Dropdown
I have no intention of working at this time Dropdown
CRIMINAL HISTORY
Do you have current criminal charges?Dropdown
If yes, what? Text field
If yes, next court date: Date
Are you on probation supervision?Dropdown
If yes, PO NameText field
PO Phone:Number field
Have you ever been arrested for any sex crimes?Dropdown
Have you ever been arrested for any arson related crimes?Dropdown
List arrests, convictions, sentences, prior prison or jail commitments, and probation history:
Age: Number field
Charge: Text field
Convicted?Dropdown
Age: Number field
Charge: Text field
Convicted?Dropdown
Age: Number field
Charge: Text field
Convicted?Dropdown
RECOVERY GOALS
Are you speaking to people or going to places that are a danger to your recovery?Dropdown
If yes, please tell us why, explain: Text field
What are three of your short-term goals (60 days):
1. Text field
2. Text field
3. Text field
Have you taken any steps toward achieving these three goals over the last 30 days?Dropdown
If yes, how? If no, why not? Text field
SELF BIO
Please tell us about yourself in your own words: Paragraph
Please tell us why you desire to participate in Sober Living Services: Paragraph
What abilities and skills do you possess that will help you be successful in your recovery: Paragraph
What areas do you need the most support in: Paragraph
What decisions have you made in the past that interrupted your recovery process? Paragraph
What actions do you think you will need to take to accomplish long-term recovery: Paragraph
Where do you see yourself in three months:Paragraph
Where do you see yourself in six months:Paragraph
Where do you see yourself in one year:Paragraph
SOBER LIVING
Tucson Recovery Homes offers two shared rooms with two people (max tenancy is four (4) participants) and we have one house manager onsite. We will review your application and notify you as soon as there is an opening!
By signing, I attest that all information provided is true and complete to the best of my ability:
Client/Participant Signature Signature
Date Date
Client/Participant Printed Name Client first name Client last name
Welcome to Tucson Recovery Homes Sober Living
Structured, Peer-Based Recovery Housing in Tucson, Arizona
Our Goal
To provide a supportive, substance-free living environment that encourages accountability, independence, and sustained recovery. Our non-clinical services complement outpatient treatment and empower residents to reach their personal goals.
Mission
Tucson Recovery Homes is committed to offering a compassionate and structured living space for those in recovery. We strive to create a nurturing environment that promotes emotional, physical, and spiritual well-being. Through peer support, structured living, and dedicated guidance, our mission is to help each resident build the resilience, strength, and skills necessary to maintain a lasting, healthy recovery.
Scope of Service
As a licensed Sober Living Home (SLH) in Arizona, we provide the following non-clinical support services:
On-Site and On-Call Staffing
Trained staff are available around the clock to ensure a structured, safe and supportive environment.
Weekly Goal Planning
Participants attend weekly planning meetings to check in, set and track personal recovery goals, employment or other milestones and work on life skill development.
Non-Clinical Case Management
Our staff assists with:
- Peer Support - Guidance and support for re-entering the workforce, pursuing education, rebuilding family relationships, or achieving long-term housing stability, etc.
- Provider Coordination - We maintain communication with outpatient programs, case managers, therapy providers, legal representatives and officers, or family members to support continuity of care with your consent.
- Linkage to community-oriented support needs
- Linkage to concierge recovery services
- Housing transition and stability planning
- Transportation coordination
- Drug & Alcohol Screening - Random and scheduled urinalysis (UA) testing helps maintain a clean and accountable environment.
As a licensed Sober Living Home (SLH) in Arizona, we offer the following ancilliary service:
Sober Transport
We offer transportation to attend:
- IOP
- Legal obligations
- Recovery support meetings
- Medical Appointments
- Job Interviews
What We Do NOT Provide We do not offer clinical or medical services onsite. This includes:
- Therapy or psychiatric care
- Clinical assessments or diagnoses
- Medication management
- Medical detox or behavioral health treatment
These services must be accessed through licensed Behavioral Health Residential Facilities or outpatient providers.
Eligibility This program is ideal for individuals who:
- Have completed or are enrolled in outpatient or step-down treatment (IOP, PHP, MAT)
- Require supportive, substance-free housing
- Are ready to engage in structured living and pursue recovery goals
- Can commit to participation in house meetings, goal planning, and community responsibilities
Next Steps: Intake Process
1. Complete and submit this self disclosure application.
2. Submit other Required Documentation:
*Government-issued ID
*Proof of current status: Sobriety Certification - THREE DAYS PRIOR TO MOVE IN
*Emergency contact information
3. Schedule Intake Interview
*Conducted by program staff to assess program fit, readiness, and house expectations
4. Arrange Payment and Schedule Move-In Date
5. Orientation & Move-In
*Review house rules and expectations
By signing, I attest that I have read and understand the Welcome page information above:
Client/Participant Signature Signature
Date Date
Client/Participant Printed Name Client first name Client last name
Contact Us
Questions about the process or eligibility?
Tucson Recovery Homes
Phone: 520-901-0184
Email: tucsonrecoveryhomes@gmail.com
We look forward to supporting your journey towards lasting recovery