General Questions

First Name *
Middle Name *
Last Name *
Date of Birth *
Gender *
Ethnicity (For Demographics Only)
Home Address
Phone Number *
Email *
If you are currently in a treatment facility and do not have access to your phone, what number should we call to reach you? Please include the name of the facility if applicable
Marital Status *
Emergency Contact Name *
Emergency Contact Number *
Relation to Emergency Contact *
Are you currently employed? *
If you are currently employed, where?
Are you able or do you have assistance to afford the program fees associated with The Sober Pad? *

Recovery Questions

Do you believe that you need detoxification? *
Are you currently in treatment for substance abuse? (Therapy, PHP, IOP, etc) *
Please list all past treatment and/or sober living facilities you've attended *
What is your drug of choice? *
Sobriety Date *
Do you have a sponsor? *
Are you, or are you open, to working a 12-step program? *
How do you believe The Sober Pad can assist you in reaching your recovery goals? *

Medical Questions

Please list any medical issues/conditions, psychiatric or mental health diagnoses: *
List any known allergies
Have you been tested for HIV? *
What were the results of your HIV test?
Have you been tested for Hepatitis C? *
What were the results of your Hepatitis-C test?
Do you have any disabilities? If yes, what are they: *
Please list all medications
Prescribing Physician Name, Phone, and Address
Are you currently enrolled in a Medication-Assisted Treatment program with a licensed physician (MAT)? *
If yes, do you agree to:

1) Store your medications according to our medication storage policy and procedure during your stay with us?

2) Take your medication as prescribed

3) Keep your medication confidential and not disclose your medication to other residents?
Have you traveled out of the country in the last 30 days?
Have you come in contact with anyone with an infectious disease?
Have you had a fever in the last 30 days?
Have you been tested for COVID-19?
Date of last COVID-19 test?
Please describe any psychiatric incidents in the past. (Overdoses, suicide attempts, hospitalizations, history of hallucinations): *

Legal Status History

Any history of harm to yourself or another? *
If yes, please describe the treatment received:
Please list any current or past criminal charges *
Are you court-ordered to sober living or on probation?
Are you a registered sex offender? *
Are you on community control? *
Are you on house arrest? *
Signature *