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DEMOGRAPHICS

Enter your full name *

Enter your phone number *

If you have an email address, add it here: *

Your previous street address *

Your previous city *

Your previous state *

Your previous zip *

Your previous country

Your social security number *

Your date of birth *

Gender *

If female, pregnant?

Yes
No
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Is smoker? *

Yes
No
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Which do you smoke?

Tobacco
Vape
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Marital status *

Married
Civil Union
Divorced
Separated
Widowed
Never Married
Other
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Spouse's full name (if applicable)

What is your primary language? *

Enter the full name of the person we can contact in case of emergency *

Enter your emergency contact's phone number *

How are you related to your emergency contact *

Emergency contact address *

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LEGAL INFORMATION / HISTORY

Do you have any pending cases? *

Yes
No
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If yes, explain

Previous involvement with the criminal justice system? *

Yes
No
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If yes, explain

Are you currently on probation or parole? *

Probation
Parole
Neither
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Criminal justice contact / PO full name

Criminal justice contact / PO phone number

Number of arrests in the last 30 days

Have you been arrested for, or have you ever been the subject of a case that involved arson? *

Yes
No
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If yes, what was the year of the arrest?

Have you been arrested for, or have you ever been the subject of a case that involved sexual assault *

Yes
No
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If yes, what was the year of the arrest?

Have you been arrested for, or have you ever been the subject of a case that involved sexual offense against a minor *

Yes
No
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If yes, what was the year of the arrest?

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HEALTH STATUS

Do you currently experience, or have a history of psychiatric conditions? *

Currently Experiences
History Of
Not Applicable
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If applicable, describe / list:

Do you currently experience, or have a history of addiction disorders? *

Currently Experiences
History Of
Not Applicable
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If applicable, describe / list:

Do you currently experience, or have a history of medical conditions? *

Currently Experiences
History Of
Not Applicable
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If applicable, describe / list:

Do you currently experience, or have a history of trauma / abuse? *

Currently Experiences
History Of
Not Applicable
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If applicable, describe / list:

Are you currently taking any prescribed medications? *

Yes
No
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If applicable, describe / list:

Explain any other current health problems:

Allergies *

(i.e. food, medication, etc. Write NA if you do not have any allergies)

Current provider agency, if applicable:

(i.e. Salvation Army, and any other recovery programs)

Admission date

Current doctor / clinician / worker

Current doctor / clinician / worker phone number

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DRUG / ALCOHOL HISTORY

Drug(s) of choice *

Method of use *

Number of uses last 30 days *

Age at first use *

Do you attend AA / NA *

Yes
No
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Number of times attended in the last 30 days

Date of last use *

What is your longest period of sobriety or stability? *

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ENTITLEMENTS AND BENEFITS

Principal source of income *

None
Public Assistance
Retirement
Salary
Disability
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Benefits *

Medical
SNAP
SSD/SSI
Other
None
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Medicaid status *

Active
Not Active
Pending
Unknown
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OTHER STATE/PROVIDER AGENCY INVOLVEMENT

Are you currently working with an agency or case manager or sponsor? *

Yes
No
Not Sure
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Worker's full name

Worker's phone number

Worker's email address

Worker's organization

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REFERRAL SOURCE

Who referred you to this house? *

Self
Treatment Center
Nursing Facility
Probation/Parole
Hospital
Case Manager
Homeless Shelter
Other
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FAMILY AND SUPPORTS

Do you feel you have social supports (family, friends, etc)? *

Yes
No
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How would you describe your current relationship with your family members?

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EMPLOYMENT STATUS

Employment status *

Employed full-time
Employed part-time
Volunteer work
Unemployed (looking for work)
Not in labor force
Other
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Highest grade completed *

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HOUSING STATUS

Living situation immediately prior to this residence *

Private Residence
Single Room Occupancy
Residential care/treatment
Hospital
Prison/Jail
Homeless Shelter
Homeless (i.e: street)
Group Home
Other
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If other, specify

Reason for leaving

Have you been homeless within the last six months? *

Yes
No
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Are you at risk of homelessness? *

Yes
No
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How many of the last 30 days have you been in a controlled environment? *

(i.e. jail, hospital, group home, etc.)

Do you currently own or have a vehicle that you intend to keep on site? *

Yes
No
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INTAKE FORM

IN THE LICENSEE'S OWN WORDS

I need help with the following

Housing

Medical Care

Education

Hygiene

Cleaning

Paying Rent/Utilities

Shopping and Meal Preparation

Mental Health Services

Substance Abuse Services

Health and Wellness Services

Securing Benefits

Money/Debt Management

Opening a Bank Account

Taking Medication

Legal Assistance

Are you interested in maintaining a sober lifestyle? *

Yes
No
Not Sure
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What do you think is your biggest or most challenging issue? *

What are the relapse triggers you can recognize? *

What are your strengths? *

What specific assistance or support would best help you to reach your goals? *

Is there anything else you can tell us about yourself that would assist us in helping you meet your goals? *

INTAKE FORM

HOUSE RULES AND REGULATIONS

All Members shall be familiar with the House Rules along with Fire and Safety Procedures.
Absolutely no alcohol or alcohol use will be permitted on the property. This also applies to the use of drugs and possession of drug paraphernalia. The use of medical marijuana is prohibited on the property. Violations of this will result in immediate discharge. This same rule applies to visitors and relatives.
Members are required to attend a minimum of three recovery support meetings, and one House Meeting each week. Exceptions may be granted with approval from the House Manager. Haven Hall Residences LLC will make its best effort to host at least one weekly recovery support meeting in the Home.
Members are tested for drug and alcohol use at random. A Member that refuses any drug test may be discharged from the Home.
All rooms will be randomly inspected for cleanliness.
Threats or acts of violence toward the Staff or other Members will not be tolerated and will result in immediate discharge.
No firearms, hunting knives or other weapons are permitted in the Home.
Smoking or vaping in the Home is NOT PERMITTED and will result in immediate discharge. Smoking and vaping are only permitted in the smoking area at the back of the Home.
Gambling is strictly prohibited on the premises.
No Member will borrow or loan money to other Members.
All visitors are subject to the approval of the House Manager. No visitors are permitted on the property while under the influence of alcohol or drugs. Visitors are allowed between the hours of 8 am and 9 pm. No visitors may spend the night.
To obtain an overnight pass, Members must receive prior approval from the House Manager at least 24 hours in advance. Additionally, upon returning from an overnight pass, all Members are required to undergo a drug and/or alcohol test.
Sexual contact between Members, or Members and visitors, is not allowed on the premises.
Visitors may not use the kitchen utensils, stove refrigerator, shower or laundry facilities.
All Members are required to clean their rooms daily, and assist in keeping the Home and surrounding grounds neat and clean.
All food and snack items will be eaten in the dining area. NO FOOD UPSTAIRS OR IN THE BEDROOMS.
All Members will be responsible for keeping the kitchen cleaned, and completing chores assigned by the House Manager. No leaving dishes in the sink overnight. Store food properly in closed containers.
Members must be fully clothed (shirt, bottoms and shoes) when out of their room. Members are also expected to maintain good hygiene and personal cleanliness.
No Member will put laundry in the machines and leave the premises. Lint filters will be cleaned after each load. No laundry is allowed to be left in the laundry room.
No Member is to enter another Member's room without the other Member being there.
Members will keep the volume of their electronic devices at a level not to be heard in the hallways or stairways. Failure to do so will result in loss of this privilege. Headphones must be used after 10:00pm.
Curfew is 9:00p on weekdays, and 10:00p on Friday and Saturday night. Exceptions must be approved by the House Manager.
No sleeping on the sofas or in other Members’ bedrooms.
There will be no nude or partially nude pictures on the walls of the Member's rooms.
If a Member is discharged or leaves the Home, all sums of money paid to the Home shall be forfeited to the Home.
When discharged from the Home, all personal effects must be removed immediately. The Home will not accept responsibility for items that have been left. The home will make every effort to protect personal items and will hold them for 10 days (without assuming responsibility) to give time for the Member to make arrangements to pick them up.
The Directors of the Home have the final decision as to whether a Member is following the rules and whether the Member can remain at the Home. Every effort will be made to ensure that the Member understands the rules and is complying with the rules of the Home before the Member is discharged.
No person under the age of 18 is allowed on the premises.
No soliciting or borrowing of any kind from any of the neighbors across the street or next door on either side.
No personal furniture, refrigerators, stoves, microwaves, air fryers, etc., are allowed in rooms.
Do not leave ANY personal items in the bathroom (soap, washcloth, toothbrush, shampoo, etc.). Store them in your room.
Do not leave your trash in the kitchen or bathroom for someone else to pick up. Clean up EVERYTHING after yourself.
Upon your initial arrival, all clothing items must be washed on high heat, and you must shower immediately upon coming into the property.
Do not allow your friends or family to receive mail at this address. It will be discarded immediately.
This is a Cooperative Living Environment. If it is reported that a Member is causing conflict or breaking any of the house rules, the Member can be required to leave the premises (discharged).

I accept the house rules and regulations *

I accept
I don’t accept
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MEDIA CONSENT FORM

I hereby consent to the use of my story, photos, videos, audio, film, or any other digital or print media by the Company for promotional, educational, or other purposes deemed appropriate by the Company.

I understand and agree that:

1. I will not receive and monetary compensation for the use of this media.

2. I release the Company from any liabilities, known or unknown, that may arise from the use of this media.

3. The Company has the right to use, reuse, publish, and republish the media in whole or in part, individually or in conjunction with other photographs or images, in any medium and for any purpose whatsoever, including (but not limited to) illustration, promotion, advertising, and trade.

4. The Company is under no obligation to use the media or my story.

I accept the media consent terms and conditions *

I accept
I do not accept
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