Today's Date: *

First & Last Name: *

Date of birth: *

How did you hear of us? *

Phone #: *

Where are you staying now?

Where are you from? *

What drugs are you recovering from? *

Recovery Date: *

We have a TRI (3) Fold Approach to recovery, in which we advocate 12 step recovery, introduce you to a Loving God that you may or may not know, along with structured living. Are you willing to participate within this approach and do your best to keep an open mind and a degree of willingness? (make sure you understand this because we are going to talk about GOD ) *

When do you need in? *

Do you have a diagnosis besides chemical dependency or alcoholism?: *

Are you on any meds?: *

If so, list them?

Have you been in recovery before? *

Longest time clean? *

Have you ever been to treatment? *

How many times, if yes to the above question. *

Have you been at the BHIVE before? *

If yes, when?

Married or in a relationship? *

If married or in a relationship, where are they now?

Children? (Insert number) *

If children, where are they?

Do you have a car? *

Do you have a job? *

If yes, where? *

When are your paydays? *

Are you on disability or SSI? *

If yes, which one and what for?

Are you on probation or parole? *

If yes, what for?

Are you a registered sex offender? *

There is a $50 move in fee due immediately, $50 over the next 2 weeks, & $100 each week thereafter ... do you understand & can you agree to this rent policy? *

Situation Summary (Summarize your current situation & hopes). *