Board and Lodging Referral Form

1.  Referral Source 
Who are you completing this form for today? Dropdown

2.  Referring Party Details (if not self)
Referrer's Full Name (type Self if you are referring yourself): Text field
Referrer's Email Address: Text field 
Referrer's Phone Number: Text field 
Organization or Agency Name: Client Referred By

3. Client Information
Legal First Name Client first name
Middle InitialClient middle name
Legal Last Name Client last name

Preferred Name / Nickname:  Client nickname

4.  Board and Lodging Program Eligibility and Requirements
Does the potential resident meet ALL 4 of the eligibility criteria REQUIRED for Board and Lodging (1, 2, 3 AND 4):
1.  Comprehensive Assessment shows a need for residential care—specifically, a score of 4 on one of the last three dimensions (Dimension 4, 5, or 6)?
Note: Fax Comprehensive Assessment to 651-262-0388 to confirm eligibilty before admission and before move-in. Dropdown
2.  Will the potential resident be participating in 9 or more hours a week of IOP? Dropdown
3.  Confirmed admission and intake date into an IOP program?  Dropdown
Confirmed Outpatient Program: Text field
Date IOP Started or Scheduled IOP Intake Date:  Text field

4.  Can the potential resident meet all of our participation requirements listed below?  Dropdown

Be serious about your recovery.
Be a good member of the house and treat other residents with respect.
Attend the mandatory Sunday night house meeting.
Keep the home tidy and complete assigned daily & weekly chores.
Follow curfews, visitor rules, and overnight allowances.
Abstain from drugs, alcohol, and gambling.
Agree to random drug testing.
Attend at least 2 recovery meetings per week.
Use phone communication tool, WhatsApp and OneStep to check in/out.
Understand and abide by all terms in our participation agreement (signed before admission).

5.  Admission Details and Additional Information

Requested Move-In Date:  Date
(Before admission, resident will need completed application, faxed comp assessment with confirmed IOP, and WhatsApp and OneStep apps loaded)

Is there anything else you'd like us to know to support this client's admission and placement (e.g., special needs, legal restrictions, mental health supports, preferred location, etc.)?  
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Please type in "Referral"

Client categories

6.  Outreach
How did you hear about Stronger Sober House? Dropdown