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Application or Referral Form

Recovery Launch Pads - Participant Questionnaire

Please complete this intake form honestly and thoroughly. All information is confidential and used to ensure your safety, eligibility, and a successful experience in our sober living homes. Required information will have an ‘*’.

1. Personal Information Full Name*

Date of Birth*

Phone Number*

Email Address*

Current Address*

Gender

Preferred Pronouns

Social Security Number

Driver’s License or State ID #

State of Issue

Emergency Contact Name*

Emergency Contact Phone Number*

Relationship to You*

2. Recovery Information Primary Addictions(s)

(Select as many as you like)

Date of Last Use

Current Sobriety Date

Have you completed detox?

Are you currently attending any recovery program (AA, NA, SMART Recovery, etc.)?

If yes, which one(s)?

Do you have a sponsor?

Name (if applicable)

3. Medical & Mental Health Information Current Medications (List All): Medication #1 Name

Dosage

Quantity

Category

Frequency

Md

Notes

Pill Count

Discontinued At

Started At

Medication #2 Name

Dosage

Quantity

Category

Frequency

Md

Notes

Pill Count

Discontinued At

Started At

Medication #3 Name

Dosage

Quantity

Category

Frequency

Md

Notes

Pill Count

Discontinued At

Started At

Do you take prescribed medications for mental health?

If yes, explain

Do you have any medical conditions or disabilities we should know about?

If yes, explain

Have you ever experienced seizures, blackouts, or severe withdrawal?

If yes, explain

Do you have any allergies?

If yes, list: Medication #1 Name

Dosage

Quantity

Category

Frequency

Md

Notes

Pill Count

Discontinued At

Started At

4. Legal Information Are you currently on probation or parole?*

If yes, provide name and contact info for your PO*

Do you have any court requirements for sober living?

If yes, please describe

Are you required to attend court dates during your stay?

Are there any pending legal issues we should know about?

Are you required to register as a sex offender?*

5. Housing & Behavior Agreement Please answer each statement to acknowledge your understanding and agreement: I understand this is a drug and alcohol-free home, and any use will result in dismissal.*

I agree to regular drug and alcohol testing, including urinalysis and breathalyzer tests.*

I agree to participate in weekly house meetings and recovery activities.*

I will contribute to house chores and keep my personal and shared spaces clean.*

I will treat fellow residents and staff with respect and kindness.*

I understand that violence, threats, or possession of weapons are prohibited.*

I understand the smoking/vaping policy (outdoors only).*

I understand and agree to the visitor and pet policy.*

I agree to pay rent on time, in the amount agreed upon.*

I understand that failure to follow house rules may result in dismissal from the program.*

6. Additional Information Have you attended any treatment centers before? If so, where and when? Treatment Center History #1 Name

Address

Started

Ended

Notes

Treatment center type

Reason for Discharge

Treatment Center History #2 Name

Address

Started

Ended

Notes

Treatment center type

Reason for Discharge

What is your recent work history or current employment status? Employment History #1 Employer Name

Employment Position

Employment Income

Employment Started

Employment Ended

Employment Type

Employment Notes

Employment History #2 Employer Name

Employment Position

Employment Income

Employment Started

Employment Ended

Employment Type

Employment Notes

Have you lived in a sober living house before? If yes, where and how long? Sober Living History #1 Name

Description

Address

Admitted

Discharged

Estimated Length of Stay

Reason for Discharge

Tell us about your past recovery experience, including any programs you’ve participated in. Recovery History #1 Sobriety Date

Relapse Date

Recovery History #2 Sobriety Date

Relapse Date

What has your living situation been like over the past year? Living Arrangement History #1 Arrangement:

Started

Ended

Notes

Do you currently have a therapist or counselor?*

If yes, please provide their name and contact info. Therapist Clinician #1 Doctor Name:*

First Visit

Last Visit

What is your current marital status?

How long do you plan to stay in our program?

What step are you currently working on, if any?

Are you currently in early recovery, maintenance, or another phase?

Do you have any criminal history? If yes, please provide a brief overview. Criminal History #1 Are you currently involved with the criminal justice system?

Have you received counseling or therapy before? If yes, when and for what? Counseling History #1 Title

Description

Has child welfare or CPS ever been involved in your life? If yes, please explain. Child Welfare History #1 Case Status

Describe case in terms of duration, number of children, and ages of children

Please Enter Case #, ODHS Branch Name, Caseworker Name, Phone Number, and Case Dates

Start Date

End Date

Please list your immediate family members and any key support people in your life. Family Members #1 Name:

Birthdate

Relation

Gender

Living Together

Family Members #2 Name:

Birthdate

Relation

Gender

Living Together

What are your recovery goals for the next 30 days?

What strengths will you bring to the house community?

Is there anything else you’d like us to know?

All answers above are true to my knowledge.*