Intake Forms -

Living Hope Recovery Intake Form

Living Hope Recovery Guest Application

This information will be used to determine eligibility for guest residency at Living Hope Recovery. Please answer every question completely unless the instructions say otherwise. If you need more space to answer a question, additional pages may be submitted with this form.

General Information

Full Name:

Phone Number:

Home Address:

Date of Birth:

Email Address:

Marital Status:

Do you have children?
Yes No
List names and ages of children:

Describe your purpose for applying to Living Hope Recovery:

Anticipated length of stay:

Date last use of alcohol/drugs:

Do you own a car?
Yes No
How did you hear about Living Hope Recovery?

Referral Name:

Referral Phone Number:

Drug/Alcohol Treatment

Are you currently in treatment for drug/alcohol use?
Yes No
Name of the facility:

Name of primary counselor/case worker:

Program type:

Date started:

Expected completion date:

12 Step Involvement

Are you currently in a 12 Step program?
Yes No
How often do you attend 12 step meetings?

Do you work with a sponsor?
Yes No
Sponsor’s Name:

Sponsor’s Phone Number:

Safety - General

Describe your living situation:

Does anyone in your home use drugs or drink excessively?
Yes No
If yes, please describe:

Does your living situation involve any dangerous/abusive relationships?
Yes No
If yes, please explain:

Do you feel in danger of hurting yourself or others?
Yes No
If yes, please explain:

Have you ever attempted suicide?
Yes No
If yes, when?

Health - General

Do you have any diagnosed mental or physical conditions?
Yes No
If yes, please describe:

Do these conditions hinder your ability to care for yourself or work?
Yes No
If yes, please explain:

Medications

Please list any medications you currently take, including temporary and/or detox medicines:

Mental Health

Are you currently working with a therapist or case worker?
Yes No

Employment

Are you currently employed?
Yes No
Employer:

Position:

Length of employment:

Hours per week:

Financial

Do you receive means of financial support besides work?
Yes No
If yes, please explain:

Education

Are you currently enrolled in school?
Yes No
School Name:

Credit Hours:

Areas of Study:

Legal/Criminal Record

Do you have any pending legal issues?
Yes No
If yes, please explain:

Have you ever been convicted of a crime?
Yes No
If yes, please list convictions and years:

Are you mandated to attend treatment or community service?
Yes No
If yes, please explain:

Are you on parole/probation?
Yes No
If yes, please explain:

Agreement

By signing this application to Living Hope Recovery, you agree that all information provided is truthful and correct and that you agree to comply with all Living Hope Recovery guidelines.

Applicant’s Full Name:

Applicant’s Signature:

Date Signed:

Please download these forms, sign and return them to lovinghoperecovery@gmail.com

Intake Forms