Phoenix Sober Living Homes - Residential INTAKE Application
By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.
Resident General Information
First Name Client first name
Middle Name Client middle name
Last Name Client last name
Gender Identity Client gender
Phone Number Client phone
Email Client email
Date of Birth Client birthdate
Martial Status Client marital status
Immigration Status Radio buttons
ID Type to Be Submitted Radio buttons
ID Number and Issuing Authority Text field
Resident Financial Information
Monthly Income Amount in USD Number field
Do you have employment? If so, please list job title(s) and company(s). Paragraph
Please list income sources. Paragraph
Savings Amount in USD Text field
Will someone else or an external organization be assisting in paying for your stay? If so, please explain below. Paragraph
Monthly Expenses Dropdown
Total Amount of Monthly Expenses in USD Number field
Emergency Contact Information
Personal Emergency Contact Name Text field
Personal Emergency Contact Phone Number Text field
Personal Emergency Contact Email Address Text field
Personal Emergency Contact Relationship to You Text field
Clinical/Professional Emergency Contact Name (e.g. Doctor, Counselor) Text field
Clinical/Professional Emergency Contact Phone Number Text field
Clinical/Professional Emergency Contact Email Address Text field
Clinical/Professional Emergency Contact Relationship to You Text field
Medical Information
Do you have any allergies? If so, please explain below. Paragraph
Do you have any dietary restrictions? If so, please explain. Paragraph
Please list any medications prescribed to you that you take regularly. Include name of medicine, dosage amount, time(s) of day taken, and frequency taken. Paragraph
Do you have any medical issues we should be aware of? Please name them, if so. Examples include diabetes, COPD, etc. Paragraph
Do you have any regular medical appointments? If so, please list reason for care, name/institution of provider, and frequency of appointment. Paragraph
Probation and Parole
Are you on probation or parole? Radio buttons
If Yes, provide details below. If No, Skip to "Criminal History" Section
Probation/Parole Information Text field
Officer Name Text field
End Date Date
Officer Contact Number Text field
Criminal History
Have you ever been convicted of a felony? If YES, please explain here. Paragraph
Are you a registered sex offender? Radio buttons
If YES, please provide registration number. Text field
Resident Preferences and Habits
Do you smoke? If YES, please indicate how often. Paragraph
Are you able and willing to participate in household chores? Radio buttons
If there are any limitations on your ability to maintain cleanliness and/or personal hygiene, please indicate them below. Paragraph
What time do you normally go to bed? Text field
List activities you enjoy doing. Paragraph
Please list any concerns you have regarding living with a roommate. Paragraph
Please list anything else you would like to share, or anything else we should be aware of. Paragraph
I, the undersigned applicant, certify that all statements, answers, and information provided in this application and any accompanying materials are true, complete, and accurate to the best of my knowledge and belief. I understand that any false statements, significant omissions, or misrepresentations may be cause for the immediate rejection of this application or my immediate removal from the facility, regardless of the time elapsed before discovery.
By signing below, I acknowledge and accept these terms.
Signature