Your information: All information must be entered to be considered for funding 

Name:Client first name Client last name

Date Of Birth: Client birthdate

Phone:  Client phone

Email: Client email

Emergency Contact:

Name: Text field

Phone: Text field

SOBER LIVING ARRANGEMENTS:   All questions must be answered to be considered for funding

Where are you Staying? Rocky Mountain Sober Living     

How much are the Membership Dues? $150.00 Intake & $700.00 per month         

Do you owe a balance? Radio buttons Amount Owed? Text field

Is this your first time in sober living (circle one)? Radio buttons     

If NO, what house(s) were you at?Text field 

What were your dates of stay (MM/YY)? Text field

Have you been asked to leave a recovery residence (circle one)?   Radio buttons

If yes, why were you asked to leave? Text field

RECOVERY:    All questions must be answered to be considered for funding

How long have you been clean and sober? Text field

What is your drug of choice? Text field

Other than sober living, what steps are you taking in your recovery? Text field

What is your longest period of sobriety? Text field

How were you able to maintain your sobriety during this period? Text field 

INCOME/EMPLOYMENT:  All questions must be answered to be considered for funding

Are you currently working? Radio buttons

If yes, how long have you been at your place of employment? Text field                    

If no, what steps are you taking to seek employment? Text field

Do you receive disability benefits (SSI/SSDI/A&D)? Radio buttons       

If yes, how much do you receive a month?  Text field

Do you receive SNAP Benefits? Radio buttons         

Do you have a Valid ID Radio buttons and SSN? Radio buttons             

Are you able to work, do chores, and do activities of daily living?  Radio buttons       

RENT: All questions must be answered to be considered for funding

Have you received funding from Diversus Health in the past?  Radio buttons     

If yes, provide the date of previous funding: Text field

How will you pay your rent and other bills if you are denied funding? Text field

MEDICAL: All questions must be answered to be considered for funding

Do you currently have Medicaid or other Health Insurance (Choose one)? Dropdown 

If other, provide the name of other Health Insurance: Text field

Do you have a Mental Health Diagnosis? Radio buttons

If yes, provide a diagnosis: Text field

Have you been prescribed any Medications for this diagnosis? Radio buttons

If yes, list medications: Text field

Do you take these medications as prescribed? Radio buttons 

Are you currently working with a therapist or psychiatrist? Radio buttons

If yes, provide name and contact information, 

Name: Text field

Phone: Text field

If not, are you interested in receiving treatment?   Radio buttons

Do you have any health conditions?  Radio buttons   

If yes, list health condition(s): Text field

Have you been prescribed any medications for this condition? Radio buttons

If yes, list medications: Text field

Do you take these medications as prescribed?   Radio buttons      

LEGAL: All questions must be answered to be considered for funding

Are you on Probation or Parole (choose one)? 

Dropdown

If yes, provide the name and contact information of the Probation Officer: 

Name: Text field

Phone: Text field

Do you have any pending criminal charges?Radio buttons

If yes, please explain: Text field

Do you have any outstanding warrants? Radio buttons

If yes, please explain: Text field

Do you have any upcoming court dates?  Radio buttons

If yes, provide dates: Text field

Are you a sex offender?  Radio buttons

If yes, provide the date of the offense: Date

If yes, do you need to register?   Radio buttons    

Sober Living Letter Requirements

In your own words, please provide us with a letter stating why you should receive funding. 

All Letters Must Include

 

·        What is your history of substance use?

·        When did you start using?

·        Why did you start using?

·        Have you experienced any trauma or traumatic events?

·        Any substance use treatment you have received.

·        Any mental health treatment you have received.

·        What do you want from your recovery?

·        Provide three recovery goals.

·        What will you do to further your recovery?

·        What support system(s) do you have

·        What coping skills are working for you?

Copy and Paste the list above on the space provided below. Make sure to cover every point asked. This is an opportunity for you to explore yourself. 

Paragraph 

 

Date: Date

 

 

Sign: Signature