Lead Form (Admissions Screen)

Expectations in Sober Living (confirm willingness):

    · 100% Abstinence from all substances, must be willing to submit to random UAs/BAs and searches when deemed necessary.

    · Maintain room cleanliness and participate in daily/weekly chores as assigned by the House Manager.

    · Peer recovery engagement: (Phase dependent) Phase 1: 5 12 step meetings week.

    · Obtain a sponsor, home group and service position within the first two weeks.

    · Curfew: (Phase dependent): Starts out at 10pm on weekdays and 11pm weekend days.

    · Overnights eligibility contingent on Phase placement (no overnights for at least 30days).

    · Obtain and maintain 32-hours week work/school/volunteering.

    · Weekly House Meeting

    · Fees:

         · $900.00 – $1,200.00/month (depending on the location)

         · $200.00 one-time intake fee 


*Are you willing and able to follow these requirements? Checkboxes

I. First Contact

    a. Sober Living Applicant:

Name: Client first nameClient last name
DOB: Client birthdate
Social Security Number: SSN
Gender: Client gender
Phone Number: Client phone
Email: Client email
Employer: EmploymentHistory
Do you have a vehicle: Checkboxes
Enrolled in School: Client school
 

    b. Referral Source:

How did you hear about us:

Paragraph
 

II. Primary Contact (if different than above)

    a. Caller Information:

Name: Text field
Phone Number: Text field
Email: Text field
Relationship to prospective resident: Text field


III. Substance Use History and Information

    a. Current overview of use history:

i. Do you believe you are an addict or alcoholic: Checkboxes
ii. Primary substance(s) used: Client substances of choice
iii. When was your last use: Date
iv. Frequency and quantity of use: Text field
v. Method of intake: Dropdown
vi. Need for withdrawal medications: Checkboxes
      - If yes, please explain: Text field
vii. Total time (years) using substance(s): Text fieldyears

viii. Longest period of abstinence:

RecoveryHistory

       - What led to your relapse: Text field


ix. Have you had previous engagement within 12 step fellowships: Checkboxes

b. Treatment History and Information:

i. Current treatment provider:

TreatmentCenterHistory

 

ii. Outside treatment services you plan to continue while in sober living (IOP, therapist…etc.):
Paragraph


iii. Please list previous treatment centers including name, year attended and reason for discharge:

TreatmentCenterHistory

 

IV. Medical/Psychiatric Health Overview:

a. Overview of mental health:

i. Have you ever been diagnosed with any mental health conditions? Please include the diagnosis and approximate year received:

Client diagnosis


ii. Are you experiencing any thoughts of suicide: Checkboxes
      - If yes, please explain: Text field
iii. Have you had any history of suicidal thoughts: Checkboxes
      - If yes, please explain: Text field
iv. Are you currenty engaging in any self injurious behaviors (cutting, burning, hitting): Checkboxes
      - If yes, please explain: Text field
v. Have you had a history of engaging in any self injurious behaviors (cutting, burning, hitting): Checkboxes
      - If yes, please explain: Text field
vi. Are you experiencing any thoughts of homicidal ideation: Checkboxes
      - If yes, please explain: Text field
vii. Have you had any history of homicidal ideation: Checkboxes
      - If yes, please explain: Text field
viii. Are you currently at risk of behaving violently: Checkboxes
      - If yes, please explain: Text field
ix. Have you had any history of violence: Checkboxes
      - If yes, please explain: Text field
x. Are you currently engaging in any eating disorder behaviors: Checkboxes
      - If yes, please explain: Text field
xi. Have you had any history of any eating disorder behaviors: Checkboxes
      - If yes, please explain: Text field

b. Overview of physical health:

i. Medical conditions/history. Please include the diagnosis and approximate year received:
Client health problems
ii.  List of all current medications psychiatric or otherwise. Please include medication name, doseage, frequency and reason precribed:

Medication

iii. Prescriber and PCP (if different):

1.     Prescriber: 
    a. Name: Text field
    b. Phone Number: Text field

2.     PCP:
    a. Name: Text field
    b. Phone Number: Text field
iv. Any known allergies: Client allergies
v. Insurance information (include company name, policy number, policy holder name and relation of policy holder to client): Insurances

V. Legal history overview:

i. Are you currently on parole or probation: Checkboxes
      - If yes, please provide your PO's information below (be sure to include name, county, phone number and email in the notes section):
           Probation

ii. What previous charges will be found on a background check (everything beyond traffic offences; include charge, year charged and outcome): 

Paragraph

iii. Are you court mandated to participate in treatment or sober living services: Checkboxes
      - If yes, what specifically is required: Text field
iv. Any convictions of violent crimes: Checkboxes
      - If yes, list the specific charge, date, and description: 
Paragraph
v. Any convictions of sex crimes: Checkboxes
      - If yes, list the specific charge, date, and description:
Paragraph
v. Do you have any outstanding warrants: Checkboxes
      - If yes, list the specific charge, date, and description:
Paragraph

VI. Emergency Contacts (please pride two):

i. Contact

VII. Payment:

a. Monthly fees of $900 - $1,200 (depending on location) can be afforded: Checkboxes