Intake For Placement

HMIS #

Intake_Form.pdf

Name: D.O.B. Race:

Phone Number: (Cell/Work)

S.S. # DL #

Last Address (If any):

Homeless: Y or N How long homeless?

Are you on parole or probation at this time?

Parole or probation officers name:

County: Phone Number: ( )

Have you ever served in the Armed Services? Y N

If yes, when?

In case of emergency: (List 2 Contacts)

Name: Relationship:

Phone: Phone:

Name: Relationship:

Phone: Phone:

Primary drug of choice:

Are you under any doctor's care? (Psycological/Medical)

If yes, where? How long?

Are you taking prescription medication?

Name of medication: How long:

Sponsorship/Meetings:

Sobriety/Clean Date:

Do you have a sponsor?

Name of sponsor:

What are your goals for recovery?

How will you be paying your rent? (Please check one)

Weekly Bi-Weekly Monthly

How long do plan on residing at this residence?

I agree that if I have any legal issues I am solely responsible for them.

I agree that if for any reason I become incarcerated, I will lose my living space.

RCI has zero tolerance for breaking rules. I agree that if I am found in violation of or regulations, use of any mind altering substances, I will be terminated immediately.

By signing this intake, I am stating that I will abide by this and any other rules as stated in the orientation packet. I will be subject to eviction from Recovery Contacts, Inc. campus immediately.

House Member Date

House Manager Date

Staff Member Date

Intake_Form.pdf