| Your information: All information must be entered to be considered for funding |
| Name:Client first name Client last name |
| Date Of Birth: Client birthdate |
| Phone: Client phone |
| Email: Client email |
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Emergency Contact:
Name: Text field
Phone: Text field
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| SOBER LIVING ARRANGEMENTS: All questions must be answered to be considered for funding |
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Where are you Staying? Rocky Mountain Sober Living
How much are the Membership Dues? $150.00 Intake & $700.00 per month
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| Do you owe a balance? Radio buttons Amount Owed? Text field |
| Is this your first time in sober living (circle one)? Radio buttons |
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If NO, what house(s) were you at?Text field
What were your dates of stay (MM/YY)? Text field
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| Have you been asked to leave a recovery residence (circle one)? Radio buttons |
| If yes, why were you asked to leave? Text field |
| RECOVERY: All questions must be answered to be considered for funding |
| How long have you been clean and sober? Text field |
| What is your drug of choice? Text field |
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Other than sober living, what steps are you taking in your recovery? Text field
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| What is your longest period of sobriety? Text field |
| How were you able to maintain your sobriety during this period? Text field |
| If coming from Detox, what made you decide to go to Detox? Text field |
| INCOME/EMPLOYMENT: All questions must be answered to be considered for funding |
| Are you currently working? Radio buttons |
| If yes, how long have you been at your place of employment? Text field |
| If no, what steps are you taking to seek employment? Text field |
| Do you receive disability benefits (SSI/SSDI/A&D)? Radio buttons |
| If yes, how much do you receive a month? Text field |
| Do you receive SNAP Benefits? Radio buttons |
| Do you have a Valid ID Radio buttons and SSN? Radio buttons |
| Are you able to work, do chores, and do activities of daily living? Radio buttons |
| RENT: All questions must be answered to be considered for funding |
| Have you received funding from Diversus Health in the past? Radio buttons |
| If yes, provide the date of previous funding: Text field |
| How will you pay your rent and other bills if you are denied funding? Text field |
| MEDICAL: All questions must be answered to be considered for funding |
| Do you currently have Medicaid or other Health Insurance (Choose one)? Dropdown |
| If other, provide the name of other Health Insurance: Text field |
| Do you have a Mental Health Diagnosis? Radio buttons |
| If yes, provide a diagnosis: Text field |
| Have you been prescribed any Medications for this diagnosis? Radio buttons |
| If yes, list medications: Text field |
| Do you take these medications as prescribed? Radio buttons |
| Are you currently working with a therapist or psychiatrist? Radio buttons |
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If yes, provide name and contact information,
Name: Text field
Phone: Text field
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| If not, are you interested in receiving treatment? Radio buttons |
| Do you have any health conditions? Radio buttons |
| If yes, list health condition(s): Text field |
| Have you been prescribed any medications for this condition? Radio buttons |
| If yes, list medications: Text field |
| Do you take these medications as prescribed? Radio buttons |
| LEGAL: All questions must be answered to be considered for funding |
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Are you on Probation or Parole (choose one)?
Dropdown
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If yes, provide the name and contact information of the Probation Officer:
Name: Text field
Phone: Text field
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| Do you have any pending criminal charges?Radio buttons |
| If yes, please explain: Text field |
| Do you have any outstanding warrants? Radio buttons |
| If yes, please explain: Text field |
| Do you have any upcoming court dates? Radio buttons |
| If yes, provide dates: Text field |
| Are you a sex offender? Radio buttons |
| If yes, provide the date of the offense: Date |
| If yes, do you need to register? Radio buttons |
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| Sober Living Letter Requirements |
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In your own words, please provide us with a letter stating why you should receive funding.
All Letters Must Include
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· What is your history of substance use?
· When did you start using?
· Why did you start using?
· Have you experienced any trauma or traumatic events?
· Any substance use treatment you have received.
· Any mental health treatment you have received.
· What do you want from your recovery?
· Provide three recovery goals.
· What will you do to further your recovery?
· What support system(s) do you have
· What coping skills are working for you?
Copy and Paste the list above on the space provided below. Make sure to cover every point asked. This is an opportunity for you to explore yourself.
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Date: Date
Sign: Signature
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