Potential Client/Resident Intake Form

NOTE ABOUT MAINTENANCE MEDS FOR OPIOID ADDICTIONS
Please do not apply if you are using Methadone, Suboxone, or other MAT’s
Monthly Vivitrol injections are the only exception.

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

First Name

Last Name

DOB

SSN

Phone

Gender

State

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Relation

Are you presently employed ?

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 intervew.

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?

Yes

List any diagnosed mental health conditions or disorders.

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

Yes

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

Yes

Are you on any maintenance meds?

Yes

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

I have read and do agree to your House Rules