Intake Questionnaire

All information is confidential

Important: All information provided is confidential and will be used solely for admission consideration and program planning. Please answer all questions honestly and completely.

Personal Information

First Name *

Last Name *

Date of Birth *

Phone Number *

Email Address *

Current Address

Emergency Contact Name *

Emergency Contact Phone *

Recovery History

Clean/Sober Date (if applicable)

Please describe your substance use history *

Have you completed any treatment programs? *

If yes, please provide details about your treatment history

Medication Assisted Treatment (MAT)

Are you currently on Medication Assisted Treatment (MAT)? *

Medical & Mental Health

Do you have any medical conditions we should be aware of?

Are you currently taking any medications (other than MAT)?

Have you been diagnosed with any mental health conditions? *

If yes, please describe

Are you currently experiencing suicidal thoughts? *

If you are experiencing a mental health crisis, please call 988 (Suicide & Crisis Lifeline) immediately.

Legal & Employment

Do you have any pending legal matters? *

If yes, please provide details

Current Employment Status *

What are your employment goals?

Financial Information

Current source of income *

Can you pay monthly house fees? *

What are your long-term housing goals? *

Goals & Motivation

Why do you want to live at Crossroads Sober Living? *

What are your primary recovery goals? *

What challenges do you anticipate in maintaining your sobriety?

What support do you need to be successful at Crossroads?

References

How did you hear about Crossroads? *

Professional Reference #1 (Name)

Phone

Relationship

Agreement

I certify that the information provided in this questionnaire is true and complete to the best of my knowledge. *I understand that admission to Crossroads Sober Living is subject to review and acceptance of the house guidelines and contract. *I authorize Crossroads to conduct a background check if necessary. *

* Required fields