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219-200-0497

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About Us
Intake Form
Contact

Home
Services
Gallery
About Us
Intake Form
Contact

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Call us Now!

219-200-0497

Intake Form

Please complete the following intake form truthfully and thoroughly. All information is kept confidential and used solely for the purpose of maintaining a safe, supportive environment for all residents.

Download Intake Form

Personal Information

Full Name

Date of Birth

Height

Weight

Phone

Email Address

Emergency Contact Name

Emergency Contact Phone Number

Identification & Legal

Do you have an identification card?

Yes No

Have you ever been convicted of arson?

Yes No

Are you required to register as a sex offender?

Yes No

Have you ever been convicted of a child abuse-related offense?

Yes No

Verified against FamilyWatchdog registry

Yes No (completed by staff)

Medical Information

Allergies

Current Medications

Do you have any functional impairments or disabilities that could affect your comfort in the home?

Yes No

Do you have any mobility issues (e.g., difficulty using stairs)?

Yes No

Are you comfortable sleeping on a top bunk if needed?

Yes No

Mental Health History

History of self-harm:

Yes No

History of suicidal ideation:

Yes No

Any current suicidal thoughts, plans, means, or intention to harm self?

Yes No

Recovery Information

Sobriety Date

Longest Period of Sobriety

How did you stay sober:

Why are you seeking to move into a sober living home?

Previous Recovery Residences Attended (if any):

I affirm that the information provided is true and accurate to the best of my knowledge.