Into Action Sober Living Application
"Together, We are Into Action"
General
What is your first name?
Client first name
What is your last name?
Client last name
When is your birthdate?
Client birthdate
What is your gender?
Client gender
What is your marital status?
Client marital status
Are you a veteran?
Client veteran status
Who referred you to Into Action?
(Please be accurate. You may type a new name if they do not pop up in our list)
Client Referred By
Recovery is a team effort. Please provide the contact information for your support network and other stakeholders in your recovery. Be sure list and list the following:
1) Emergency Contact (at least one);
2) Referent listed above;
3) Any care providers and stakeholders in your recovery, including Probation/Parole.
(Provide as much contact information as may be available to you)
Contact
Please list your immediate family members (spouse/partner, children, parents, siblings). This is to better understand your family dynamics.
Family Members
Enter your insurance information here.
Insurance
What is your sobriety 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
Do you have a history of self harm? If yes, please provide some background information.
Checkboxes
Client medical notes
Any suicidal or homicidal ideation? If yes, please provide some background information.
Checkboxes
Client medical notes
To submit a request for a reasonable accommodation due to a disability, please submit a request in writing to the operator, seperately from this application. You may request a Reason accommodation Request form from the operator at info@intoaction.net.
Medications
List the medications you are currently prescribed.
Medication
Who will you be using for ongoing medication management (including MAT)? Please list all therapists, doctors and providers.
SUD Treatment History
Are you currently in treatment?
Dropdown
If yes, where?
Text field
When is your anticipated discharge date?
Date
Have you been to treatment before? If so how many times and where?
Have you lived in sober living before? If so, where, and how long was your stay? What was the result? Provide as much background as you are comfortable with.
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Financial
Are you currently employed?
Checkboxes
Tell us what you plan to do for employment. At Into Action Sober Living, residents are required to work, attend school, or volunteer for a minimum of 30 hours per week.
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Do you have any other sources of income?
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Into Action Sober Living charges a recovery housing fee of $225.00 per week, and a $200.00 one time admission fee ($425.00 total deposit). How do you plan on covering the initial deposit and the ongoing costs of the home?
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Tell us about your living situation over the last 90 days. Where were you staying?
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If yes, please provide the name and contact information for the supervising officer:
Into Action Sober Living uses a 12 step based recovery model. While encouraging multiple pathways to recovery, we ask that all residents agree to work a 12 step program, in addition to, or combined with, others methods of recovery. Do you agree to work a 12 step program?
If already engaged in a 12 step program, please tell us where you are at in that process, and whether you have a sponsor. Provide some details about your experience so far in your recovery program.