Potential Client/Resident Intake Form

NOTE ABOUT MAINTENANCE MEDS FOR OPIOID ADDICTIONS

We allow Suboxone if you agree to an exit plan with a health provider. We also permit Vivitrol injections.
No Methadone.

IMPORTANT - WE ARE EXCLUSIVELY FOR PEOPLE IN TREATMENT OR ACTIVE PARTICIPATION IN RECOVERY.

We cannot respond to requests from people who are looking for housing for any other purpose.

This form is used to collect information for internal purposes only. The information you provide will remain confidential and privileged. Please answer all questions fully and accurately to the best of your knowledge.

Personal Information

Name(Required)

First Last

DOB(Required)

SSN

Phone(Required)

Gender(Required)

State(Required)

Email(Required)

Emergency Contact Name(Required)

Emergency Contact Phone(Required)

Emergency Contact Relation(Required)

Are you presently employed?

Company name

Company contact

Phone

Please provide a brief summary of your history of drugs or alcohol use, legal history, dates of incarceration if applicable, present situation, source of funds, work history, job skills or desires, whatever else gives us a good starting point for an interview.(Required)

History

Were you referred by a program such as The Way Home, DC Justice, or other organization that has agreed to fund all or part of your initial expenses?(Required)

Yes

Name of organization(Required)

Contact name(Required)

Phone(Required)

Email(Required)

What is your initial source of income?(Required)

Mental Health

List any diagnosed mental health conditions or disorders.(Required)

Please fill in your details here - if none, then just type "None."

Medical

Do you struggle with any health issues that preclude you from normal Activities of Daily Living?(Required)

Yes

If you answered Yes to question 1, Please list any diagnosed physical conditions and chronic illnesses or pain issues.(Required)

Can you walk two flights of stairs? Are you able to lift up to 40 lbs?(Required)

Yes

Are you on any maintenance meds?(Required)

Yes

Please list prescriptions, reason for taking each, how often and dosage?(Required)

House Rules(Required)

I have read and do agree to your House Rules

All Christian Grace Supportive Homes’ have as their main goal Relapse and Recidivism prevention.

Our homes run best when residents have an equal voice. No resident is a manager or has any authority over another. Each resident is a welcome guest, who should feel safe and comfortable in a supportive atmosphere. A Director or Owner will recommend procedures such as weekly chores and maintenance, and oversee meeting schedules, events and disputes.

For everyone’s sobriety and safety, our rules are not suggestions!

As a resident you will be agreeing to a set of rules, and a program that includes complete abstinence from drugs or alcohol. We cannot allow medical marijuana or maintenance meds Suboxone, Methadone et al, in our sober living homes. Many Re-Entry candidates do not have substance abuse issues, and should definitely not start a new chapter by committing to abstinence.

Your agreement to these rules means that you understand that there is no landlord / tenant protections in place for you as a resident. You are not leasing a room from a landlord, you are participating in a program of sobriety and community re-entry. There is NO LEASE, only a set of rules and terms.