Sacred Hearts Application
To be considered for residency at Sacred Hearts, applicants must meet the following criteria:
1. Age: Must be at least 18 years of age.
2. Medical Clearance: Must be medically cleared if a drug screen is positive for substances requiring medical detoxification, such as alcohol or benzodiazepines.
3. Total Sobriety Commitment: Must be committed to maintaining abstinence from drugs and alcohol at all times.
4. Drug Testing: Resident is willing to be drug tested upon arrival.
5. House Responsibilities: Resident is willing to participate in household chores, attend all required house meetings, and pay weekly dues on time.
6. Behavioral Expectations: Resident agrees to adhere to a code of conduct that prohibits aggressive behavior and requires respect for the house and property of others.
7. Meeting Attendance and Home Group: Resident agrees to attend 12-Step meetings or other approved recovery meetings along with getting a home group.
8. Sponsor: Resident agrees to get a sponsor and work the 12 steps with that sponsor.
IF YOU ARE INTERESTED IN THE MEN'S WE WILL BE TAKING APPLICATIONS ON SEPT 1.
Welcome to the Sober Homes intake wizard
Click next to begin!
General
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
When is your birthdate?
Client birthdate
What is your race/ethnicity?
Client race
What is your gender?
Client gender
What is your marital status?
Client marital status
Spouses Name:
Contact
Are you a veteran?
Client veteran status
Medical History
Tell us about your medical history.
What is your clean date?
Recovery history 1 relapse date
What is your substance(s) of choice? Add multiple by clicking in the box and selecting different options
Client substances of choice
Have you been clinically diagnosed with anything? Add multiple by clicking in the box and selecting different options
Client diagnosis
Do you have any history of Self Harming?
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Do you have any health problems? Add multiple by clicking in the box and selecting different options
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
Do you need Assistance with any of the following daily activites:
Checkboxes Text field
If yes to any of these please explain:
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Do you use any supports or devices to help you with daily living? (for example, cane, walker, hearing aids, adaptive tools, caregiver assistance?)
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Have you had any of the following tests?
Medical Tests
Medications
List the medications you are currently prescribed.
Medication
Who is your Medical Provider?
Therapist/Clinician
Occupancy
What date do you plan to be admitted on?
Client admit date
Do you currently have transportation? If yes, Please list Make, Model, and Year of vehicle.
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Please provide valid insurance with your name listed as a driver.
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Do you agree to follow the rules of the program?
Are you currently involved in any legal proceedings or criminal justice system? Please explain
Are you currently under any supervision with the legal system. (I.E. Probation, Parole, Recovery Court,Community Corrections, Pre-trial).
If yes, Please list your Officers Name, Phone Number, and Email.