Resident Intake Application | All Under One Roof

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Date of Intake

01Personal Information

Full Legal NamePreferred NameDate of BirthAgeContact NumberEmail AddressCurrent Address

03Recovery History

What is your clean date?How long have you been in recovery?Substances you primarily struggled withDate of last use of alcohol or drugs

Have you completed detox?

YesNo

Have you completed residential treatment? If yes, where and how long?

Currently in outpatient treatment?

YesNo

Have you ever lived in a recovery residence before?

YesNo

Have you ever been discharged from a recovery residence? If yes, explain.

04Most Recent Program

Most recent recovery, treatment, detox, rehab, or transitional program attendedProgram LocationDate EnteredDate Completed or Discharged

Was the program at least 30 days?

YesNo

Did you successfully complete the program?

YesNoCurrently Enrolled

Reason for discharge (if not completed)

05Recovery Support

Do you have a sponsor or recovery mentor?

YesNo

Sponsor's NameSponsor's Contact NumberHow long has this person been your sponsor?

Do you attend recovery meetings?

YesNo

How many meetings each week?Which recovery program(s) do you participate in? (NA, AA, SMART Recovery, Celebrate Recovery, Other)

06Medication

Currently taking prescribed medications?

YesNo

Please list your medications, dosages, and reasonCurrently receiving MAT? If yes, which medication?

Can you provide a current medication list?

YesNo

Do you agree to follow our medication storage policy?

YesNo

07Medical & Mental Health

Current or previous medical conditions, hospitalizations, surgeries, or ongoing concerns

Currently under the care of a physician or provider?

YesNo

Physician / Provider NamePhysician / Provider Contact

Any accessibility needs?

YesNo

Currently receiving counseling or behavioral health services?

YesNo

Anything else that would help us support your recovery?

08Known Allergies

Do you have any known allergies?

YesNo

List medication, food, environmental, or other allergies and reactions

Do you carry an epinephrine auto-injector or emergency allergy medication?

YesNoNot Applicable

09Legal Information

Currently on probation or parole?

YesNo

Supervising officer name and phoneAny upcoming court dates?Any legal restrictions affecting residency?

11Financial Readiness

Can you pay the $250 intake fee?

YesNo

Can you pay the $175 weekly program fee?

YesNo

Will another person or agency help pay your fees? If yes, who?

12Emergency Contact

Emergency Contact NameRelationship to ApplicantPrimary Contact NumberAlternate Contact NumberEmail AddressEmergency Contact Address

13Motivation

Why are you seeking recovery?What are your recovery goals for the next six months?What strengths will you bring to the house?What challenges do you anticipate?Why is All Under One Roof the right fit for you?

14Program Commitment

I agree to and understand each of the following as a condition of admission:

Abstinence-based recovery housingRandom drug/alcohol testingFollow house rulesAttend required recovery meetingsParticipate in peer support activitiesUnderstand and observe curfewRespectful behavior at all timesUnderstand violations may result in dischargeFollow medication storage policy

15Required Documents

Please indicate which documents you can provide:

Photo IDSocial Security CardBirth Certificate (if available)Insurance CardMedication List30-day supply of prescribed medicationsTreatment discharge paperworkProbation/parole paperwork (if applicable)Employment verification (if employed)

16Additional Information

Any additional medical, recovery, safety, accessibility, dietary, or personal information we should know?

17Applicant Certification

I certify that the information provided on this intake form is accurate and complete to the best of my knowledge. I understand that withholding or providing false information may affect my eligibility for admission or continued participation in an All Under One Roof LLC program. I understand that this form is used for intake, placement, safety, and program-planning purposes. I authorize All Under One Roof LLC to contact my emergency contact when reasonably necessary to protect my health or safety.

I certify and agree to the statement above.Applicant's Printed NameApplicant's Signature (typed)Date

Submitting opens your email client with your application addressed to allunderoneroof624@gmail.com. Prefer to send another way? Call 205-645-4522 or 205-502-6282.

Begin the next chapter of your recovery.