Application

Sober Homes Application

Thank You for your interest in Purple Mountain Recovery's Sober Living Homes. We offer Level 3 and 2 sober livings. All our sober living are LGBTQIA2+ and Ally orientated and All Gender Inclusive. If this is not for you please do not apply. We require a $100 Intake Fee as well as Full month rent upon move in. If you can not afford this there is multiple resources available to help you with your first month. Please let us know in this application if you need helo with this and we will send you resources. It is important to note we will not allow anyone to move in without payment or verified funding first. At this time we do not accept vouchers from Parole or Probation. We are committed to helping you in your recovery journey and guarantee to work as hard as you at it. We do not hold beds or guarantee bed availability unless the non-refundable intake fee is paid upon interview and acceptance. Please in any funding requests do not put us down without us first interviewing you for acceptance and confirming availability. Once approved you will receive the contract with all house rules, requirements etc. These vary based on Level of home. Just to mention a couple very important ones before you decide to apply: 1. We require all participants to have a peer coach and meet with case management weekly. 2. We require a mandatory weekly Life Skills group at the house. 3. We require mandatory house meetings 2xs a month with our Sober Living Director. 4. We require all participants to complete madatory UA's weekly being done at our office, and we require all participants to carry a very small (it can be put on a key chain)  BA machine with them at all times for random BA's.5. Finally and most important we do not tolerate hate, discrimination, or dishonesty in anyway shape or form. We believe everyone has a chance at a safe place to recovery from mental health, substance, or co-occuring disorders. If you have any questions before filling this out pease email soberliving@purplemountainrecovery.org
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General

Tell us about yourself
What is your Legal full name?
Text field
What is your Preferred first name? (if same as legal name please enter that)
Client first name
What is your Preferred last name? (if same as legal name please enter that)
Client last name
What name do you prefer to go by?
Client nickname
What are your pronouns?
Client pronoun
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
Are you a veteran?
Client veteran
 
 

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: If none out N/A
Client Address
City:
Client City
State:
Client State
Zipcode:
Client Zip

Contacts

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

Insurance

Enter your insurance provider(s).
Insurance

Medical History

Tell us about your medical history.
When was your last use 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 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

Have you had any of the following tests?

Medical Tests
 

Medications

List the medications you are currently prescribed.
Medication

Treatment Centers

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

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.
SoberLivingHistory

Employment

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