Sunlight of the Spirit House is a multiple pathways recovery organization with housing for men & women who are seeking support, accountability, & community. 

Today's Date: Date  Time: Text field

Name of person filling out this form? Text field

Name of interested resident: 

Client first nameClient last name

Date of Birth: Client birthdate

Phone number: 

Client phone

Email address:

Client email

What treatment center/where are you currently staying? 

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What is your case manager's name (if applicable)?

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What is your case manager's phone number? 

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What is your case manager's email address? 

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What is your anticipated discharge date/date you'd like to move into the house? 

Date

Why do you want to live in a recovery house? 

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Have you ever lived in a recovery house before? 

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If yes, please provide the name of the house, how long you lived there & why you left: 

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What are your substances of choice? select, click again in the box to select multiple

Client substances of choice

Tell us about your substance use & recovery history? 

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What is the date of your last drink/drug use? List sobriety date, relapse date not required

RecoveryHistory

Please list the medications you take/dose: 

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Please list any mental health diagnosis select, click again in the box to select multiple 

Client diagnosis

Briefly describe your employment history & what you do for work? 

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Are you on probation or parole? 

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If yes, 1) identify the type of supervision, 2) county in which you are on probation/parole and 3) the requirements of your supervision: 

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Have you ever been charged with a violent crime? If yes, please explain: 

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Have you ever been charged with a sexual crime? If yes, please explain: 

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Do you have any disabilities that impact your activities of daily living? e.g. taking the stairs, brushing your hair, doing chores

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If yes, please explain: 

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Have you reviewed the requirements of Sunlight of the Spirit House program?

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Do you have any questions about our program?  

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If yes, please describe.

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Is there anything else you want to add?

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