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Intake Form - Complete Form

First name*

Last name*

Email

Cell Phone

Date of birth*

Height*

Weight*

Marital Status*

Single

Married

Divorced

Employment Status*

Currently Employed

On workers compensation

Disabled

Not currently employed

If employed: Company Name

Do you have a car you will be bringing to the house?*

Yes

No

Do you have a driver's license?*

Yes

No

Is your car insured?

Yes

No

Do you currently have health insurance?*

Yes

No

If yes, what insurance company?

Are you currently on any medications? If so list them along with dosages

Do you currently have a mental health diagnoses? If yes please list

Please list all food and medication allergies*

Any other medical conditions for us to be aware of?

Currently in treatment?*

Yes

No

Are you currently on probation or parole?*

Yes - Probation

Yes - Parole

No - Neither

Have you been convicted of a violent crime?*

Yes

No

Have you been convicted of a sex related crime?*

Yes

No

Have you ever been convicted of Arson?*

Yes

No

Have you ever experienced an Overdose?*

Yes

No

Have you ever had a Heart Attack or Stroke?*

Yes - Heart Attack

Yes - Stroke

Yes - Both

No - Neither

Recovery Questions

Length of sober time*

Have you been to AA or any 12 Step based fellowship?*

Yes - Alcoholics Anonymous

Yes - Narcotics Anonymous

Yes - Opiates Anonymous

Yes - Other Fellowship

No - Never been

Are you willing to engage in 12 Step Meetings? Getting a sponsor, commitment, working the 12 steps and finding a home group.*

Yes

No

Have you been in Sober Living?

Yes

No

Acknowledgements

I understand Integrity Homes is a self pay house with $800/rent due on the first of the month.

I understand and agree to weekly drug testing provided by Integrity Homes

I understand and acknowledge that Integrity Homes has the right to remove me from the home if my drug test returns a positive result

Emergency Contact Name*

Emergency Contact Phone*

Emergency Contact Relation to You*

Family Member

Friend

Significant Other

Other

Home
About

Contact

Nassau County Men's Sober House

CONTACT

IntegrityhomeLI@gmail.com

516-210-5049

112 Elliott place

Freeport, NY 11520

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