MA1. Intake Form

 

Allied Comprehensive Recovery Network (ACRN) Intake

Welcome to the ACRN intake wizard

 


1. The ACRN Sober Living community requires a one-time $150 administrative processing entry fee (covers background check and urinalysis).

2. The community fee is $1,250 monthly. We only require a 30-day minimum community fee commitment, and there is no maximum length of stay as long as members are in full compliance with the community. The community fee must be paid before community admittance. All community fees are due on the 1st of each month. A $50 late fee may be assessed for any late payment. Residents will be made aware of payments of fees made on their behalf from third party payers.

3. All community and administrative fees are non-refundable. There will be no refunds for any reason under any circumstances. 

4. Must be 18 years of age or older.

5. Must be willing and able to work, volunteer full-time, attend school or attend some form of outpatient treatment within 30 days of admission.

6. I understand that the ACRN Sober Living community requires complete abstinence from non-prescribed drugs and alcohol. Any use of drugs and alcohol is strictly prohibited and may result in immediate discharge from our residence(s). 

7. Disruptive and discourteous behavior within our residence(s) or community will not be tolerated and may result in discharge from our residence(s).

8. A Member must be able to pay his/her community fee on time. Failure to do so may result in discharge from our residence(s).

9. ACRN Sober Living provides furniture, utilities, bedding, towels, cooking and eating supplies, and household cleaning/laundry supplies. You are responsible for providing your own food, clothing, and personal items, as well as arranging your own transportation. 

 


Intake Criteria


To ensure the success and safety of all residents, individuals must meet the following criteria to be eligible for admission into the sober living home:

Criminal Background History

Applicants with convictions of a sexual nature ("sex offender"), arson, and certain violent crimes will not be admitted.

Physical Health


Applicants must be in good physical health and capable of managing daily activities without the need for significant medical supervision or assistance.
Applicants must provide documentation of a recent health evaluation (if required) to confirm they are medically stable.


Mental Health Stability


Applicants with a mental health diagnosis must be independently compliant with prescribed medications and demonstrate stability for a sustained period before admission.
Applicants must not present immediate risks to themselves or others, such as suicidal ideation, aggression, or acute psychiatric symptoms that require a higher level of care.

Substance Use Recovery


Applicants must demonstrate a commitment to recovery, including: Being free from drugs and alcohol for a minimum period (e.g., 30 days, if applicable).
Willingness to participate in random drug and alcohol testing as part of the program.
Applicants must not exhibit behaviors or conditions indicative of withdrawal or detoxification needs at the time of admission.
Medication assisted treatment (MAT) is allowed, with the exception of methadone and Suboxone at this time.

Legal and Behavioral Considerations


Applicants must not have a history of violent or dangerous behavior that would pose a threat to the safety of other residents or staff.
Applicants with legal issues (e.g., probation or parole) must provide documentation verifying compliance with legal obligations.

Financial Responsibility


Applicants must agree to and demonstrate the ability to meet the financial requirements of the program, such as rent or program fees.
Financial assistance may be available for eligible individuals, but applicants must communicate any financial constraints during the intake process.

Willingness to Participate


Applicants must agree to abide by the house rules, including maintaining sobriety, attending required meetings, and participating in recovery-related activities.
Applicants must demonstrate a willingness to engage in communal living and contribute positively to the sober living environment.

Referral or Endorsement


Applicants must provide a referral or endorsement from a qualified professional, such as a therapist, counselor, or recovery sponsor, confirming their readiness for this level of care.


Transportation


Applicants must have a reliable means of transportation for attending work, appointments, or recovery meetings. This may include access to public transportation, bicycles, or personal vehicles, if applicable.

Prohibited Items and Behaviors


Applicants must agree to adhere to restrictions regarding prohibited items (e.g., drugs, alcohol, weapons) and behaviors that conflict with the recovery-focused environment.


Interview and Screening


All applicants must participate in a pre-admission interview to assess readiness and compatibility with the program.
Applicants must complete an intake screening to ensure they meet the criteria and do not require a higher level of care than the sober living home can provide.

Click next to begin!

 

General

Tell us about yourself
What is your first name?
Client first name
What is your middle name? No middle name? Move on to the next question.
Client middle name
What is your last name?
Client last name
When is your birthdate?
Client birthdate
What is your race/ethnicity?
Client race
What is your gender?
Client gender
What is your marital status?
Client marital status
Are you a veteran?
Client veteran status

Contact Information

How can we reach you?
What is your email address?
Client email
At what phone number can we best reach you at?
Client phone
Street Address:
Client Address
City:
Client City
State:
Client State
Zipcode:
Client Zip

Contacts

Give us a few people that we can reach out to in case of an emergency.

Contact
 

Insurance

Enter your insurance provider(s).
Insurance

Medical History

Tell us about your medical history.
When was your last use date?
Recovery history 1 relapse date
What is your substance(s) of choice? Add multiple by clicking in the box and selecting different options
Client substances of choice
Have you been clinically diagnosed with anything? Add multiple by clicking in the box and selecting different options
Client diagnosis
Do you have any health problems? Add multiple by clicking in the box and selecting different options
Client health problems
What kind of meetings do you attend? Add multiple by clicking in the box and selecting different options
Client kinds of meetings attended
What allergies do you have? No allergies? Move on to the next question.
Client allergies

Have you ever engaged in self harm or attempted suicide? Dropdown

If yes, how long ago was the most recent occurance? Text field

Have you had any of the following tests?

Medical Tests
 

Medications

List the medications you are currently prescribed.

Medication Assisted Treatment (MAT) is allowed with the exception of methadone and Suboxone at this time.

Medication

Treatment Centers

Tell us about any treatment centers you've previously been admitted into.
TreatmentCenterHistory

Client Referral Source

 
Who referred you to us?
Client Referred By

Occupancy

 
What facility will you be staying at?
Client facility
What is the estimated length of stay?
Client estimated length of stay
 

Sober Living History

Tell us about any sober livings you've previously been admitted into.
SoberLivingHistory

Employment

Tell us about your employment status.
If you're currently unemployed select "unemployed" under "type"
EmploymentHistory

Living Arrangement

Tell us about your living arrangement prior to moving into this facility
LivingArrangementHistory