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Sober Living Ohio

Sober Living Ohio Intake Sheet

Sober Living Ohio Intake Data Sheet

NAME:
D.O.B.
AGE:
SS#:
VETERAN STATUS:
RACE:
HEIGHT:
WEIGHT:
YOUR CURRENT ADDRESS:

EMERGENCY CONTACT NAME:
EMERGENCY CONTACT ADDRESS:

EMERGENCY CONTACT PHONE:
ARE YOU CURRENTLY HOMELESS? Yes No
Do you have a homeless certification form? Yes No
Do you currently have external supervision? (For example parole, probation, or case management)? Yes No
PAROLE, PROBATION OFFICER, or CASE MANAGER:
LIST ANY CRIMES YOU HAVE BEEN CONVICTED OF:
WHEN WAS THE LAST TIME YOU USED ALCOHOL OR DRUGS?
MEDICAL INFORMATION
LIST ALL MEDICAL PROBLEMS (INCLUDING DRUG/ALCOHOL ADDICTION/MENTAL HEALTH DIAGNOSTICS):
ARE YOU PRESENTLY UNDER A PHYSICIAN OR HOSPITAL'S CARE: Yes No
IF YES, NAME OF PHYSICIAN OR HOSPITAL:
LIST ALL MEDICATIONS TAKEN IN THE PAST NINETY DAYS:
ARE YOU PRESENTLY UNDER PSYCHIATRIC CARE: Yes No
IF YES, NAME OF DOCTOR OR HOSPITAL:
ADDITIONAL INFORMATION
ARE YOU ABLE TO WORK? Yes No
PLEASE PROVIDE US WITH A BRIEF SUMMARY OF YOUR PREVIOUS WORK EXPERIENCE:
WHAT JOB SKILLS DO YOU POSSESS:
ARE YOU ABLE TO PERFORM HOUSEHOLD CHORES? Yes No
ARE YOU WILLING TO ATTEND A MINIMUM OF 3 SUPPORTIVE 12 STEP GROUP MEETINGS PER WEEK? Yes No
BACKGROUND/GOALS
1. Why do you need the Sober Living Transitional Home program?
2. What do you expect to receive from the program?
3. How long do you feel it will take you to accomplish your goals and become capable of living independently?
4. What goals will the staff and others be able to assist you in achieving?
Use the space below to express any other areas of concern or issues, which may allow us to make appropriate decisions regarding your application.
SIGN:
DATE:
 
 

 
 
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