Full Intake Form – Spero Recovery Sober Living

Name*

First Last

Date of Birth*

Drivers License #

State

Expires

License Plate #

Vehicle Make

Vehicle Model

Phone Number

Email*

Emergency Contact*

First Last

Relationship*

Emergency Contact Phone Number*

Employer*

Employer Phone Number*

Do you have health insurance?*

Yes
No

Insurance Name

Policy #

Medical Conditions / Allergies

Prescription Medications

Note that narcotic medications are not allowed / You must provide a lockbox

How long have you been sober?

Drug(s) of choice

Which 12 step meetings do you attend?

(AA, NA, CA, etc)

Sponsor Name

Sponsor's Phone Number

Have you ever lived in a Sober Living Home?*

Yes
No

If yes, which one?*

Are you involved in any legal action?*

Yes
No

If yes, please explain*

Are you required to register as a sex offender?*

Yes
No

Are you ever been convicted of arson?*

Yes
No

Are you ever been convicted of a felony?*

Yes
No

Source of income?

Salary (weekly/monthly)

Weekly Fee + $100 intake fee

David’s House Sober Community is a recovery home which, we reserve the right to impose consequences without prior notice or refund of fees, of any resident member who is found to be:

Using alcohol or drugs;
Engaging in disruptive behavior; or
In default of payment of weekly fee.

All residents of David’s House Sober Community are members of our recovery home. You do NOT have renter’s rights or any rights of tenants pursuant to the Colorado Property Code, and expressly waive any such rights in exchange for membership privileges. I have read the above notice and understand that I am applying for membership of David’s Home Sober Community as a member of a recovery home. I agree to abide by the responsibilities requirements of the house and fully subject myself to the rules of the home, which include periodic / random drug and alcohol testing. I understand that I am subject to consequences if any of the following occur: 1) I use alcohol or drugs (other than prescribed/non-narcotic medications); 2) I engage in disruptive behavior (continued patterns of irresponsible behavior are considered disruptive behavior); 3) I fail to pay my weekly fee. In understand that my deposit and fees will be forfeited.

By signing below, I certify that the information contained in this application is true. I have read and understand the David’s House Sober Community house rules and polices. I understand and accept the above conditions set forth for membership to David’s House Sober Community, and agree to abide by said conditions should I be selected as a member resident.

Consent*

I agree to this website and David's House privacy policy.

Comments

This field is for validation purposes and should be left unchanged.