Interview Form | Sober Living in Delray

Which house are you applying to?

Personal Information

First Name *

Last Name *

Date of Birth *

Phone Number *

Email Address *

Expected move in date to Sober Living in Delray

Referral Source (organization/person)

Treatment Center *

Treatment Start Date *

Treatment End Date *

Therapist Name

Therapist Phone

Discharge Planner Name

Discharge Planner Phone

What level of treatment will you have completed at the time of your discharge? *

What level of treatment is your treatment center recommending for you after your discharge? *

Do you plan to follow through with your treatment center's recommendation? *

YesNo

Vehicle Information

Make

Model

Year

License Plate

Emergency Contact

Name *

Phone *

Relationship *

I consent to Sober Living in Delray contacting my emergency contact listed above about my stay and any incidents that may occur.

Sobriety & Substance History

Do you identify as someone who struggles with drugs and/or alcohol? *

YesNo

Medical & Legal

Current Medications

Any Current Legal Issues / Probation / Parole? *

YesNo

Have you ever been arrested? *

YesNo

Are you a registered sex offender? *

YesNo

Employment Status

Financial Obligations

1. How do you plan to meet the initial intake/move-in fee associated with entering the recovery residence?

2. How do you plan to meet your ongoing weekly/monthly housing payments while residing at the recovery residence?

Health & Safety

Are you a past resident of Sober Living in Delray? *

YesNo

Have you ever been diagnosed with an eating disorder? *

YesNo

Do you have any self harm issues? *

YesNo

Have you ever attempted suicide? *

YesNo

Are there any health issues we should be aware of? *

YesNo

Your Recovery Journey

Why are you seeking sober living at this time? *

What are your goals for your time in recovery? *

Do you plan on working a program of recovery while at Sober Living in Delray? *

YesNo

Do you currently have a sponsor? *

YesNo

Acknowledgement

By signing below, I confirm that the information provided in this form is accurate and complete to the best of my knowledge. I understand that this is an intake inquiry form and does not guarantee placement.

Full Name (Signature) *

Date *