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Kaylinn’s Promise

Resident Intake Application

(Confidential – For authorized staff only)

Section 1: Personal Information

Full Legal Name *

Perferred Name

Date of Birth

Age

Phone Number *

Email address

Current Address (Street, City, State, ZIP)

Emergency Contact Name

Relationship to You

Emergency Contact Phone Number

Gender Identity

Male
Female
Other

Are you a veteran?

Yes
No

Section 2: Recovery Background

Primary Substance(s) Used

Date of Last Use

Length of Sobriety (if applicable)

Prior treatment centers or sober living homes attended

Have you ever been discharged from a program?

Yes
No

If yes, please explain

Are you currently on probation or parole?

Yes
No

Probation/Parole Officer Name & Contact

Referral source (Agency, Treatment Center, or Self)

Section 3: Health & Behavioral Information

Medical conditions or disabilities

Current medications (name, dosage, frequency)

Do you take medications as prescribed?

Yes
No

Mental health diagnoses or treatment history (PTSD, anxiety, depression, etc.)

Allergies or dietary restrictions

Are you under medical or psychiatric care?

Yes
No

Provider or Clinic Name

Are you able to self-administer your medications?

Yes
No

Section 4: Employment & Financial Information

Are you currently employed?

Yes
No

Employer name and work schedule

If not employed, what is your plan for a meaningful day?

Do you receive income (disability, unemployment, etc.)?

Yes
No

Source of income

How will you pay weekly program fees ($175 due Fridays by 6 PM)?

If you agree, check boxes

I understand fees are non-refundable and due on time
I will notify staff before any financial hardship

Section 5: Residence Expectations

If you agree, check boxes

I will live in a structured, drug- and alcohol-free environment
I agree to random drug and alcohol screening
I will attend at least 3 recovery or support meetings per week
I will participate in house meetings and complete assigned chores
I will follow quiet hours, curfew, and house rules
I understand overnight guests (including children) are not permitted
Visitors must be approved by staff

What do you hope to gain from living at Kaylinn’s Promise?

Section 6: Safety & Confidentiality

Do you have any current safety concerns or suicidal thoughts?

Yes
No

Describe any triggers or safety concerns staff should know about.

If you agree, check boxes

I understand my information is confidential under HIPAA and 42 CFR Part 2
I consent to communication with my case manager, probation officer, or referring provider (if ROI signed)

Section 7: Acknowledgment & Signature

If you agree, check boxes

I certify that all information is true and complete
I understand this application does not guarantee placement
I agree to follow Resident Handbook and OKARR/NARR standards

Typed Name / Signature

Date of Submission