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

Emergency Contact:

Name: Text field

Phone: Text field

SOBER LIVING ARRANGEMENTS:   All questions must be answered to be considered for funding

Where are you Staying? Rocky Mountain Sober Living     

How much are the Membership Dues? $150.00 Intake & $700.00 per month         

Do you owe a balance? Radio buttons Amount Owed? Text field
Is this your first time in sober living (circle one)? Radio buttons                 

If NO, what house(s) were you at?Text field 

What were your dates of stay (MM/YY)? Text field

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

Other than sober living, what steps are you taking in your recovery? Text field

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

 If yes, provide name and contact information, 

Name: Text field

Phone: Text field

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

Are you on Probation or Parole (choose one)?



If yes, provide the name and contact information of the Probation Officer: 

Name: Text field

Phone: Text field

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            
Sober Living Letter Requirements

In your own words, please provide us with a letter stating why you should receive funding. 

All Letters Must Include

·        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. 



Date: Date



Sign: Signature