Application / Intake Form

Starts With Love Foundation  


Tell us about yourself

What is your first name?
Client first name
What is your middle name? No middle name? Move on to the next question.
Client middle name
What is your last name?
Client last name
Have you ever been known by an alternate name?
Text field
When is your birthdate?
Client birthdate
What is your race/ethnicity?
Client race
What is your gender identity?
Client gender
What is your marital status?
Client marital status
Are you a veteran?
Client veteran
Social Security Number:
Driver's License or State Issued Identification Number or other Identification Card Number:
Text field
Who is completing this application?
Radio buttons

Contact Information

How can we reach you?

What is your email address?
Client email
At what phone number can we best reach you at?
Client phone
Street Address:
Client Address
Client City
Client State
Client Zip
Do you consent to a background check?
Radio buttons

I agree to be contacted by Starts With Love Foundation-Saguaro House via SMS, email, or phone using the information I provided for the purposes of reviewing my application.


Give us a few people that we can reach out to in case of an emergency.



Enter your insurance provider(s). This information will be utilized in case of a relapse so we can help find a detox facility for you. 


Medical History

Tell us about your medical history.

When was your last relapse date?
Recovery history 1 relapse date
What is your substance(s) of choice? 
Client substances of choice
Have you been clinically diagnosed with anything? 
Client diagnosis
Do you have any health problems? 
Client health problems
What kind of meetings do you attend? Add multiple by clicking in the box and selecting different options
Client kinds of meetings attended
What allergies do you have? No allergies? Move on to the next question.
Client allergies

Have you had any of the following tests?
Medical Tests

Do you have any issues ascending or descending stairs?
Radio buttons

Let us know if you have any mental health issues or diagnosis?
Text field

Do you have a history of self-harm?
Radio buttons


List the medications you are currently prescribed including the dosage.


Treatment Centers

Tell us about any treatment centers you've previously been admitted into.


Client Referral Source


Who referred you to us?
Client Referred By

Sober Living History

Tell us about any sober livings you've previously been admitted into.



Tell us about your employment status.
If you're currently unemployed select "unemployed" under "type"

All residents are required to seek employment, be enrolled in school at least part-time, or take part in volunteer work up to 32 hours per week.
What are you plans?

Living Arrangement

Tell us about your living arrangement prior to moving into this facility


Program Details

How will you pay for the program? Apple Pay, Zelle, and Cash are accepted.

Do you have any concerns sharing a room?
Radio buttons

Are you able to perform household chores?
Radio buttons

What is your sober or clean date?

When would you like to move in?
Text field

Why do you want to live in a sober & clean house?
Text field

How did you hear about our program?
Text field

What other information should we consider when reviewing your application?
Text field

Why do you think you are a good fit for a sober and clean living opportunity?
Text field