Referred individual Name:Client first nameClient last name

Date: Date

APPLICATION AND INTAKE QUESTIONNAIRE

(To be completed by resident applicant. This does not guarantee admittance.)

Personal Information:

Full Name:  Client first name Client last name

Current Address:  Client Address

City: Client City State: Client State  Zip Code: Client Zip

Phone Number: Client phone    Email Address:Client email

Pronouns: Client pronoun    Gender: Client gender   VAStatus: Client veteran status    Marital Status: Client marital status   Race: Client race

Birthdate: Client birthdate

Recovery Information:

How long has it been since you have last used illicit drugs or alcohol? Text field

What is your drug of choice? 

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 Have you completed any formal addiction treatment programs or therapy?

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If yes, please provide details (including the name of the program, duration, date completed).

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 Are you currently attending any support group meetings (e.g., AA, NA, SMART Recovery)?

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Do you have a sponsor, recovery mentor, pastor or similar person in your life that you are actively working with?

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Contact Information: Client sponsor

Emergency Contact:  Contact  Client phone   Client Address

 Are you on Probation? 

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If yes, who is your probation officer?

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Our fee is $135 per week to live in our sober living homes. Do you have the means to pay these fees?

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What is your source of income?

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Recovery Program Information:

Why do you want to live in a recovery home? 

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What do you expect to get out of living in a recovery home?

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 Have you previously lived in a recovery home or a sober living environment?

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If yes, please provide details: 

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Are you willing to participate in regular drug and alcohol testing while living in the recovery home?

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Are you committed to maintaining abstinence from illicit drugs and alcohol during your stay at the recovery home?

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Are you willing to attend Samaritan Works Program educational classes, attend NA/AA meetings, and follow Samaritan Works Recovery Plan?

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Are you willing to attend a health care provider of your choice for substance abuse disorder counseling and keep Samaritan Works updated on progress?

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Are you willing to only use prescription medications that are prescribed to you by such health care providers and only take them as they have been prescribed?

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Are you open to participating in house meetings and other recovery-related activities as required by the recovery home's policies?

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Do you have any specific goals or plans for your recovery while living in the recovery home?

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Policies and Procedures Agreement:

I understand that living in a recovery home requires adherence to its policies and procedures. I have received a copy of the recovery home's rules and regulations and agree to abide by them. I understand that non-compliance may result in eviction from the recovery home.

 

Signature:

 Signature

Date: Date

Please use this space to provide any additional information or comments you believe are important for us to consider in your application.Paragraph