Intake

Sober Living Intake Form

3 pages15 fieldsHIPAA-ready
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Sober Living Intake Form

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Applicant Full Name
Jane Martinez
Date of Birth
03/15/1985
Email Address
jane.martinez@email.com
Phone Number
(555) 867-5309
Employment & Income Status
Select status...
Legal / Probation Status
Option A
Option B
Option C
Substance Use History
Enter details here...
Sobriety Date
03/15/1985
Treatment History
Enter details here...
Current Medications
Mental Health Conditions
Diabetes
Hypertension
Asthma
Heart Disease
Recovery Support & Meeting Attendance
Option A
Option B
Option C
Emergency Contact
Contact person
House Rules Consent Agreement
I agree to the terms above
Sign here
Applicant Signature
Sign here
Submit
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The Sober Living Intake Form is a comprehensive application and admission document designed for sober living homes, halfway houses, recovery residences, and transitional housing programs that serve individuals in early addiction recovery. As the recovery housing industry formalizes standards and best practices through organizations like NARR (National Alliance for Recovery Residences), operators need structured intake processes that evaluate applicant readiness, document clinical and personal history, and establish clear expectations through a house rules agreement. This sober living intake form replaces informal or paper-based admission workflows with a professional, HIPAA-compliant digital process.

The form collects essential personal information including demographics, identification details, employment and income status, legal involvement or probation and parole requirements, and the referral source (treatment center, court order, self-referral, or community organization). A detailed substance use history section documents the applicant's primary and secondary substances of use, duration and pattern of use, date of last use, and sobriety date. The treatment history section captures prior residential treatment, detoxification, intensive outpatient, outpatient counseling, 12-step or mutual aid participation, and medication-assisted treatment experience. Current medications are documented through a structured medications list that includes dosage and prescribing provider, which is particularly important for residents on MAT medications such as buprenorphine, naltrexone, or methadone.

The intake concludes with two critical sections: an emergency contact form that identifies a family member, sponsor, or support person who can be reached in case of a crisis, medical emergency, or relapse event, and a detailed house rules consent agreement that the resident must acknowledge and sign. The house rules consent covers expectations around drug and alcohol testing, curfew compliance, chore participation, meeting attendance requirements, guest policies, rent payment schedules, conflict resolution procedures, and grounds for immediate discharge. By digitizing this entire intake process, recovery housing operators maintain organized resident files, demonstrate compliance with state and national standards, and create a professional first impression that reflects the quality of their program.

What's included

  • Personal demographics with employment, income, and legal status
  • Comprehensive substance use timeline with sobriety date tracking
  • Treatment history across all levels of care and recovery support
  • Medication list with MAT documentation for clinical coordination
  • Emergency contact and crisis support person identification
  • House rules consent agreement with resident e-signature
  • Medical conditions checklist

Who uses this template

  • Sober living homes and halfway houses processing new resident applications
  • Recovery residences documenting substance use and treatment history for admission screening
  • Transitional housing programs establishing house rules acknowledgment and consent
  • Court-ordered or probation-referred recovery housing programs maintaining compliance records

All form fields

15 fields across 3 pages. Customize any field after signing up.

Applicant Full NameText
Date of BirthDate
Email AddressEmail
Phone NumberPhone
Employment & Income StatusDropdown
Legal / Probation StatusMultiple Choice
Substance Use HistoryLong Text
Sobriety DateDate
Treatment HistoryLong Text
Current MedicationsMedications
Mental Health ConditionsConditions
Recovery Support & Meeting AttendanceMultiple Choice
Emergency ContactEmergency Contact
House Rules Consent AgreementConsent Agreement
Applicant SignatureE-Signature
8 min saved per patient98% patient satisfaction3x faster than paper

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