Lead Form

Revenant Recovery Sober Living Application


Expectations in Sober Living

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

- Maintain room cleanliness and participate in weekly chores as assigned by HM. 

- Peer recoveyr engagement: (Phase Dependent) Phase 1: 5 meetings a week, sponsor, homoe group, and service position 

- Curfew (Phase Dependent): 10 PM Weekdays, 11 PM Weekend

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

- 32 hours week work/school/volunteering 

- Weekly House Meeting 


I. First Contact 

a. Potential Resident

Name: Client first nameClient last name

DOB: Client birthdate

Gender Identity: Client gender

Phone Number: Client phone

Email: Client email

Employer: Text field

Has Transportation: Text field

Enrolled in School: Text field

b. Referral Source (How did you hear about us?)

Text field

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: Text field

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. Route of intake: Text field

vi. Need for withdrawal medications: Text field

vii. Time (years) using substance: Text field

viii. Have you had previous time in recovery/how long: Text field

ix: Have you had previous engagement within the 12 steps: Text field

1. If the answer is yes to either of the two above, what led to your relapse:


b. Treatment History and Information

i. Current and past treatment providers and projected discharge date: 



ii. Outside treatment services you will continue (IOP, Therapist, etc) 



IV. Medical/Psychiatric Health Overview: 

a. Current overview of mental health history

i. Have you ever been diagnosed with any mental health conditions

Client diagnosis

b. Current risk/thoughts of suicide: Text field

i. History of


c. Current risk/thoughts of self harm (cutting, burning, etc): Text field

i. History of


d. Current risk/thoughts of eating disorder: Text field

i. History of


e. Current risk/thoughts of harm to others: Text field

i. History of


f. Current overview of health history

i. List of all current medications, psychiatric or otherwise: 



ii. Prescriber and PCP (if different) 

1. Prescriber

a. Name: Text field

b. Number: Text field

2. PCP

a. Name: Text field

b. Number: Text field

iii. Medical conditions/history: 

Client health problems

iv. Any known allergies: 

Client allergies

v. Insurance information: 


V. Legal History Overview: 

a. Are you currently on parole or probation: Text field

i. If so: 

1. Probation/Parole Officer's Information

a. Name: Text field

b. Phone Number: Text field

c: Email: Text field


2. Charges: 


ii. Are you court mandated to participate in treatment or sober living services: Text field

1. if so, what specifically is required: 


iii. Previous convictions (everything beyond traffic): 


iv. Any convictions of violent crimes: Text field

1. If so, list the specific charge, date, and description: 


v. Any convictions of sex crimes: Text field

1. If so list the specific charge, date, and description: 


vi. Do you have any outstanding warrants: Text field

1. If so, list the specific charge, date, and description: 


VI. Emergency Contact



VII. Payment (fees start at $1000/month depending on location and room)  

a. Monthly fees can be afforded:Text field