We’re honored that you’re considering becoming part of our sober living community. This application is your first step toward building a meaningful, sober life rooted in support, structure, and the healing power of the outdoors.
Please take your time, answer honestly, and know that all responses are kept confidential.
When you're ready, click Next at the bottom of the page to begin.
Basic Information
First Name: Client first name
Middle Name: Client middle name
Last Name: Client last name
Preferred Name (if different): Text field
Date of Birth: Client birthdate
Biological Gender: Client gender
Marital Status: Client marital status
Phone Number: Client phone
Email Address: Client email
Social Secuirty: SSN
Current Address: Client Address
RKYMTN Recovery Participant Questionnaire
Desired Entry Date:
Date
How long do you expect to stay at RKYMTN Recovery?
Text field
Do you have a valid Colorado ID or driver's license?
Checkboxes
Do you have a valid birth certificate?
Checkboxes
Do you have a valid Social Security card?
Checkboxes
Do you have a primary mode of transportation?
Checkboxes
Are you willing and able to complete household chores?
Checkboxes
Do you have concerns about sharing a room?
Checkboxes
Please describe your current living situation:
Paragraph
Have you ever been in another housing program within the last 90 days? If yes, please explain:
Paragraph
Do you have children under the age of 18 years old?
Checkboxes
Are you currently employed?
Checkboxes
Are you able to work?
Checkboxes
If you answered "yes" to being currently employed, please answer the following questions.
Place of employment? Text field
Position? Text field
How long have you been employed? Text field
How many hours per week do you work? Text field
Anticipated weekly or bi-weekly income? Text field
Do you have any additional employment not disclosed?
Checkboxes
How do you plan to pay for the program?
Paragraph
Substance Use Questionnaire
What substances have you used in the last 3 years?
Paragraph
What is your substance of choice?
Text field
When was the last time you used any mind altering substances, and which substance did you use?
Paragraph
When is your clean date or sobriety date?
Date
Have you been in detox before? If yes, how long ago?
Paragraph
Are you currently in active treatment (inpatient or outpatient)? If yes, where and for how long?
Paragraph
Are you participating in or considering Medication Assisted Treatment (MAT) program?
Checkboxes
If you answered yes to the previous question, please provide the location of the MAT clinic:
Text field
Type of MAT?
Text field
How is MAT administered?
Checkboxes
Do you use tobacco or nicotine products?
Checkboxes
Recovery Pathway Questionnaire
What pathway of recovery are you currently engaged in?
Checkboxes
Do you attend a 12 step meeting?
Checkboxes
If yes, which fellowship do you attend and how often?
Text field
Do you have a sponsor?
Checkboxes
Do you have a Recovery Coach?
Checkboxes
If yes, which organization does your peer recovery coach work with?
Text field
Participant Medical History
Do you have any allergies? If yes, please explain.
Paragraph
Do you have any physical health/medical conditions or disabilities? If yes, please explain.
Paragraph
Do you have any infectious diseases? If yes, please explain.
Paragraph
Do you require any stability accommodations?
Checkboxes
Do you have a history of seizures?
Checkboxes
Are you currently using any prescription medications? If yes, please explain.
Paragraph
Are you currently using any over-the-counter medication?
Paragraph
Do you have any other health conditions or concerns that RKYMTN Recovery should be aware of? If yes, please explain.
Paragraph
Do you have any mental health issues or diagnosis? If yes, please explain.
Paragraph
Do you have a history of self-harm?
Checkboxes
Have you ever experienced suicidal ideations, attempts, or reieved in-patient treatment for self-harming behavior? If yes, please explain.
Paragraph
Court & Criminal Justice Questionnaire
Do you consent to a background check?
Checkboxes
Are you currently involved in any legal proceedings or criminal justice issues? If yes, please explain.
Paragraph
Do you have any community service requirements?
Checkboxes
Do you have any court ordered treatment requirements?
Checkboxes
Do you have any pending sentencing or possible jail time upcoming?
Checkboxes
Do you have a Department of Corrections number?
Checkboxes
Have you ever been charged or convicted of arson?
Checkboxes
Have you ever been charged or convicted of a felony? If yes, please list charges.
Paragraph
Have you ever been charged or convicted of abuse or neglect of any person, including but not limited to a diabled person, senior, or child?
Checkboxes
Are you affiliated with a gang?
Checkboxes
Have you been charged or convicted as a sex offender in any state? If yes, please explain.
Paragraph
Are you currently on probation or parole?
Checkboxes
Do you have any restraining orders in place? If yes, please explain.
Paragraph
Insurance & Benefits Questionnaire
Do you have health insurance?
Checkboxes
If yes, please provide insurance provider:
Insurances
Do you have Medicaid benefits?
Checkboxes
If yes, please provide your member number:
Text field
Participant Statement & Consents
I consent to be contacted by RKYMTN Recovery via SMS, email, or phone using the information I provided for the purposes of reviewing my application.
Checkboxes
Are you willing to submit to random drug and alcohol screening?
Checkboxes
Why is your recovery important to you?
Paragraph
Have you previously lived in sober housing?
Checkboxes
If yes, please provide when and where:
Text field
Have you ever been discharged from a sober living home?
Checkboxes
If yes, please explain:
Paragraph
Why do you think you are a good fir for sober living?
Paragraph
What do you want to accomplish while participating in the RKYMTN Recovery program?
Paragraph
How did you hear about RKYMTN Recovery?
Text field
Were you referred to RKYMTN Recovery? If yes, who?
Text field
Please provide any other information about yourself or your situation that you feel is important to your application review.
Paragraph
Outdoor Recreation Readiness
RKYMTN Recovery incoropartes outdoor activities (fly fishing, hiking, camping, service projects) as part of the recovery journey.
Are you physically able to participate in outdoor activities?
Checkboxes
Do you have any limitations or restrictions we should be aware of? If yes, please explain.
Paragraph
Do you enjoy being outdoors or in nature?
Checkboxes
Would you be willing to engage in regular peer-supported recreation activities?
Checkboxes
Financial Responsibility
Weekly Program Fee: $250
How do you plan to pay your weekly fee?
Checkboxes
Do you understand that all fees are due in advance and late payments may result in consequences of being discharged from the program?
Checkboxes
Please initial: Initials Text field
Participant Declaration
By signing below, I confirm that the information provided is accurate and complete to the best of my knowledge. I understand that any false statements may lead to denial or discharge from the program. I have reviewed the rules, expectations, and recovery commitment required at RKYMTN Recovery.
Signature
Date
Thank you for taking the time to complete your application!
At RKYMTN Recovery, we believe that recovery is not just about abstaining from substances, it's about rediscovering who you are, building a life rooted in purpose, and finding strength through connection, accountability, and community.
Your willingness to take this step is a powerful act of courage, and we’re honored to walk alongside you on this journey. We look forward to learning more about you and welcoming you into a space that is grounded in respect, structure, and the healing power of the outdoors.
We’re glad you’re here. Let’s build something strong, together!
Return to RKYMTNRecovery.com