1. Personal Information

First Name Client first name
Middle Name Client middle name
Last Name Client last name
Gender Client gender
Date of Birth Client birthdate
Social Security Number (SSN) SSN
Email Address Client email
Phone Number Client phone

Marrital StatusClient marital status
Referral Source: How were you referred to Phoenix Sober Living Homes? Text field
Veteran Status: Client veteran status

Veteran Status (if Yes, What branch?): Text field

2. Emergency Contacts

Family Members

MANDATORY:

Emergency Contact Name: Text field

Emergency Contact Number:Text field

Emergency Contact Address: Text field

Emergency Contact Relation: Text field

3. Social Services & Assistance Needs

Do you need help with:

SNAP / Food Stamps? Checkboxes
Social Security or Driver's License assistance? Checkboxes
Finding a Primary Care Physician? Checkboxes
Finding a Dentist? Checkboxes
Counseling/Therapy? Checkboxes
Other Needs: Do you have other social service needs not mentioned? Text field

4. Recovery & Substance Use History

Drug(s) of Choice: Client substances of choice

Recent Use: What other drugs/alcohol have you used in the last 6 months? Text field
Sobriety Date: What is your most recent sobriety/clean date?Date
Longest Sobriety: What is your longest period of sobriety? Text field
Longest Active Use: What was your longest period of active use? Text field
Detox History: Have you completed detox? Checkboxes 

If Yes: When and where? Text field

 

Sober Living History: Have you lived in a Sobriety House before? Checkboxes

If Yes: Name and location? Text field

 

12-Step History: Have you ever worked a 12-step program? Checkboxes

If Yes: Which program? Text field

 

Sponsor Info:

Sponsor Name Text field

Sponsor Phone Text field

 

Current Counseling:

Organization Name Text field
Counselor Name Text field
Phone Number Text field

5. Treatment History

TreatmentCenterHistory

6. Legal Information

Felony History: Have you ever committed a felony? (Yes/No + Explain) Radio buttons

If you selected yes, explain Text field
Sex Offender Status: Are you a registered sex offender?  Radio buttons
Assault Charges: Do you have any assault charges on record? Radio buttons

If Yes, explain Text field
Pending Charges: Are any charges pending against you? Radio buttons

If Yes, explain Text field

DUI History:

Have you been charged with a DUI?  Radio buttons
Count & Details (State/Date for up to 3 DUIs)

Paragraph

Probation/Parole:

Are you on State/Federal Parole? Radio buttons

If Yes, Officer Name/Phone Text field

Are you on County Probation? Radio buttons

If Yes, Officer Name/Phone Text field

Are you in Specialized Courts (Drug, Mental Health, Veterans)? Radio buttons

If Yes, Court Name Text field

7. Medical History & Health

Infectious Disease Status:

Hepatitis C - Tested Radio buttons Result  Radio buttons
Tuberculosis - Tested Radio buttonsResult  Radio buttons
HIV - Tested  Radio buttons Result  Radio buttons

General History:

Seizures: History of seizures? Radio buttons |  Date of last seizure Text field
Overdoses: Have you ever overdosed?  Radio buttons| How many times? Text field
Suicide Attempts: Have you attempted suicide?  Radio buttons| How many/Date of most recent Text field
Medical Issues: Do you have any chronic medical issues? (Paragraph
Allergies: Do you have allergies (Food, Animal, Meds)? Checkboxes. Details Text field

Providers:

Primary Physician (Name/Phone/Address) Paragraph

Preferred Hospital Paragraph
Dentist (Name/Phone/Address) Paragraph

8. Detailed Medication Information

Medication

9. Insurance Information

Insurances

 

If Yes: Company Name, Member ID, Group #, Provider Phone (back of card).
Government Assistance:

Medicare / Medicaid? (Yes/No)
Disability (SSD/SSI)? (Yes/No)
Plan Name & ID #.

10. Narrative & Agreement

Personal Statement: Why do you want to live at the Sobriety House?

Paragraph

Certification:

Truthfulness of Information I, the undersigned Applicant, hereby certify that all statements, answers, and information provided in this application—including medical history, legal status, and financial information—are true, complete, and accurate to the best of my knowledge. I understand that providing false information, significant omissions, or misrepresentations is a violation of Phoenix Sober Living Homes policy and may constitute grounds for the immediate rejection of this application or my immediate discharge from the facility, regardless of when the discrepancy is discovered.

Electronic Signature Consent By signing below, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.

Consent to Processing I acknowledge that the information collected in this form will be stored securely and used for the purpose of assessing my eligibility for residency, ensuring safety within the home, and facilitating care coordination.

Signature

Date