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Intake Application

CLIENT RIGHTS

All services at Trinity Sober Living, Inc. are voluntary. Even after accepting services, clients have a right to terminate services at any time. Applicants for services will have equal access and can expect to be treated with respect regardless of their gender, race/color/national origin, age, sexual orientation, or physical/mental disability.

    INTAKE ASSESSMENT

    Name:

    Email:

    Phone #:

    Date:

    Referral:

    Personal Information

    Age:

    Gender:

    If female, are you pregnant?:

    If yes, due date?:

    Veteran?:

    Disabled?:

    Marital Status:

    Can you speak fluent English?

    Housing Information

    Previous/Current address:

    City:

    Zip Code:

    How long?

    If no previous address is applicable, what was your living situation immediately prior to this application :

    Reason for leaving your previous/current housing:

    Legal Information/History

    Currently on probation?

    Parole?

    Parole/Probation Officer Contact Name:

    Phone #: ()

    Pending Case(s):

    Court Dates:

    Income Information

    Source of Income:

    Employment Status

    Highest Level of Education:

    Do you own a car?

    If employed, provide company name and phone number, your position, your manager, and your days & hours of work:

    Why are you looking to become a member of Trinity Living, Inc.? What goals would you like to achieve?