Serenity Cottage Intake Form Applicant Information: Full Name * First Name Last Name Date of Birth * MM DD YYYY Phone (###) ### #### Email * Emergency Contact Information Full Name * First Name Last Name Relationship to Applicant * Phone * (###) ### #### Alternate Phone (###) ### #### Background Information Are you currently employed? * Yes No If yes, where? Do you have a source of income? * Yes No If yes, please explain Are you currently on probation or parole? * Yes No If yes, please provide your officer's contact information Substance Use/Recovery Are you currently sober? * Yes No Sober Date Do you have a sponsor? Yes No How many recovery meetings do you attend weekly? * Have you ever lived in a sober living environment before? * Yes No If yes, please list the location and your reason for leaving. Substance Use History What substances? * Check All that Apply Alcohol Opiates Methamphetamine Cocaine/Crack Marijuana Benzodiazepines If other (please specify): Age of first use? * Do you use tobacco? * Yes No Mental Health Do you have any mental health diagnoses? * Yes No If yes, please list: Are you currently taking any mental health medications? * Yes No If yes, please list: Do you have a mental health professional you are currently working with? Yes No Medical Information Do you have any medical conditions we should be aware of? * Yes No If yes, please explain: Do you have any allergies? * Yes No If yes, please list them: Legal Information Do you have any pending legal matters? * Yes No If yes, please explain: Have you been convicted of any crimes? * Yes No If yes, please explain: Personal Goals What are your short-term goals for living in sober housing? * What are your long-term goals for recovery? * We’ll get back to you shortly, thank you!
