Full Name: Client first nameClient last name
Social Security Number: SSN
Driver License Number: Text field
If you do not have a valid driver's license, list what form of ID you currently have: Text field
Phone Number in Treatment: Text field
Cell Phone Number: Client phone
Email Address: Client email
DOB: Client birthdate Sobriety Date: Text field
Give a brief statement why you are seeking Sober Living:
Have you resided in sober living in the past: Radio buttons
If yes, when, where, and for how long:
Do you have a significant other: Radio buttons
If yes, answer the questions below. If no, write N/A or leave them blank.
Name of significant other: Text field
Relationship: Text field How Long: Text field
Does your significant other use drugs or alcohol, even socially: Radio buttons
If yes, what and how often: Text field
Is your significant other supportive of your recovery and supportive of your willingness to enroll in the program at The Opal house: Radio buttons
Are you willing to sign a release of information for your significant other: Radio buttons
If no, give your reasons why:
Do you have any children: Radio buttons
If yes, please list their first names and ages only:
Who is caring for your children while you are in sober living: Text field
Are you involved in the court system regarding your children or involved with DCF: Radio buttons
If yes, please describe:
Please answer all questions below, if not applicable write N/A.
Are you currently enrolled in a treatment program: Radio buttons
If so, list the name of the facility and the house of the program:
Have you completed treatment recently: Radio buttons
If so, where, what type, and length of stay: Text field
Did you successfully complete treatment: Radio buttons
If no, please explain in detail why:
Are you willing to sign a release of information for that facility: Radio buttons
If no, state your reason why:
Do you currently have a sponsor: Radio buttons
Sponsor's first name & phone number: Text field
Are you wiling to sign a release of information for your sponsor: Radio buttons
Do you have a NA, AA, or OA network: Radio buttons
If so, how many women do you have in your network: Text field
Are you willing to attend weekly meetings and engage in 12-step recovery: Radio buttons
Do you have transporation: Radio buttons
Year, Make, and Model of Vehicle: Text field
Tag Number: Text field
List current, and previous employer
Do you have any medical issues that would interfere with working or volunteering full time: Radio buttons
If yes, please explain in detail:
Do you have any physical limitations? Are you able to care for yourself AKA showering, walking, cooking, cleaning, etc: Radio buttons
If you have physical limitations please describe:
Are you currently taking any medications: Radio buttons
If yes, please list in the space below:
Have you ever been diagnosed with any mental health issues:Radio buttons
If yes, what are the diagnoses and are your symptoms currently manageable:
Have you ever attempted suicide: Radio buttons
If yes, please describe below including dates:
Have you ever been Baker Acted to a psychicatric facility: Radio buttons
If so, when and describe:
Do you currently engage in any type of self-harm or self-mutilation: Radio buttons
If so, describe and include the date of the last time you harmed yourself:
Are you willing to sign a no harm contract if permitted into the program: Radio buttons
Do you currently have a physician who manages your medications: Radio buttons
If yes, list the name of your physician, phone number and the date of your next follow up appointment. If no, referrals will be given to you.
Have you ever been diagnosed with an eating disorder or nutritional problem: Radio buttons
Are you currently binging, purging, or restricting your food: Radio buttons
Do you have a meal/food plan you follow on a daily basis: Radio buttons
If yes, describe: Text field
Do you see a nutritionist or dietitian: Radio buttons
If yes, please provide their name, phone number, and date of your last/next appointment:
Are you willing to submit to random drug testing: Radio buttons
Are you willing to breathalyze daily: Radio buttons
Do you have any current pending legal issues: Radio buttons
If yes, describe in detail below, including any upcoming court dates:
Do you have a history of arrests: Radio buttons
If so, list the year and charges below:
Length of Stay
What is your anticipated length of stay at The Opal House: Text field
Are you willing to commit to a minimum of 6 months at The Opal House: Radio buttons
If no, please describe why:
What is your anticipated admission date: Client admit date
$150.00 Admin Fee includes: interview, intake, and drug testing. Non-Refundable Deposit is fully refundable after 6 month commitment is met.
I understand in the event I be dismissed from the program for any reason including relapse I understand that any deposit or pre-paid fees will be forfeited. Text field
I understand if I do not complete my 6 month commitment to the Opal House I understand taht any deposit or pre-paid fees will be forfeited. Text field
All information disclosed is completely confidential. A phone assessment or intake appointment will be scheduled prior to admission to the Opal House. If you have any further questions please call us at 813.474.9309 or you can visit or our website at opalrecoveryhome.com
Signature of Applicant: Signature
Printed Name: Text field
CRRA Signature: Signature
Your intials next to each statement acknowledge that you have reviewed, will abide by, and have received a copy of the house rules and regulations of The Opal House. Breaking of any of the below rules and regulations are grounds for immediate discharge from the program.
Text field 1. Must attend a minimum four 12-Step meetings per week. Meeting list to be turned into staff every Wednesday. If not enrolled in a treatment program you must attend one 12-Step meeting daily for the first 90 days.
Text field 2. Must have a sponsor within the first 7 days of admission. Report the name of your sponsor to Administrator. Must be willing to sign a release of information for your sponsor if requested.
Text field 3. Attend mandatory House Meeting held each week. Be on time. No expections. Failure to attend a house meeting could be grounds for discharge from the Opal House Program.
Text field 4. Abide by the curfew, which is 10:00 PM on weekdays and 11:00 PM on weekends for the first 30 days. After the first 30 days, the curfew is 11:00 PM on weekdays and 12:00 AM on the weekends. Any exceptions must be approved by staff one week prior. No expections.
Text field 5. You must be employed, attending school, or volunteering for a minimum of 25 hours per week within two weeks of admission. Enrollment in an outpatient or day treatment program may be substituted for employment in some cases.
Text field 6. Job search forms must be turned into Administrator at weekly House Meeting. No employment in bars, clubs, or any other environment deemed unsafe by Administrator. Must get approval prior to starting new employment.
Text field 7. If enrolled in an outpatient/day treatment program you must adhere to all treatment guidelines. Being staff discharged from the treatment program could result in termination of your contract with the Opal House.
Text field 8. Submit to random drug screening/breathalyzer immediately upon request. There are no expections and failure to do so can result in immediate termination of your contract with the Opal House.
Text field 9. No persons other than residents allowed inside the Opal House unless staff member is present or prior visitation request is approved. Approved visitors are only allowed on outside patio and/or common living area #1.
Text field 10. No males permitted on property unless approved by staff.
Text field 11. All visitors must sign in and out when entering or leaving the property. Failure to do so can result in a loss of visitation privileges.
Text field 12. All chores will be completed daily, as assigned.
Text field 13. No entering others living areas without permission and th person being present.
Text field 14. No eating/borrowing food that does not belong to you. Label all food with your name on it as well as expiration date.
Text field 15. No giving out door codes or lending of garage key. No duplicating of keys. If you forget your door code or lose a garage key report it immediately to Administrator.
Text field 16. House is to be locked and all doors secured prior to leaving.
Text field 17. Abide by laundry schedule at all times. NO chlorine bleach allowed. Color-safe bleach only. No cleaning products containing bleach are permitted.
Text field 18. No borrowing of money, cigarettes, clothing, or personal items. If you are in need, see administrator.
Text field 19. No nail polish or hair dyes allowed outside of bathroom area. Resident is responsible for any damage caused by such items.
Text field 20. The Opal House phone number is to be given out only to sponsor network or immediate family members.
Text field 21. No use of alcohol or any mood- or mind-altering substances. The Opal House has a Zero Tolerance Policy. If relapse occurs, you acknowledge that you could be discharged from the program immediately.
Text field 22. If you have an eating disorder, you must follow your food plan at all times. Not following or adhereing to your meal plan will be considered a relapse.
Text field 23. Should I be dismised from the program for any reason, including relapse, I understand any deposit or fees will be forfeited.