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Live-In Recovery Program – Intake & Referral Form

Thank you for considering SafeHope Home. Entering recovery is a courageous step. You are in control of what you share. You may skip any question that feels overwhelming. This form helps us determine together whether our program is a good fit for you at this time. Completing this form does not guarantee admission.

Preferred Contact Method
Text
Call
Email

SECTION 1: Immediate Safety Screening

Are you currently in immediate danger?
Yes
No
Have you had thoughts of harming yourself in the past 30 days?
Yes
No
Do you feel you may pose a safety risk to anyone else at this time?
Yes
No
Is anyone currently looking for you or actively trying to contact you in a way that makes you feel unsafe?
Yes
No

If any immediate safety risks are identified, SafeHope may defer intake until stabilization and a safety plan are in place.

SECTION 2: Trafficking & Safety Overlap

Are you seeking support related to experiences of exploitation or trafficking?
Yes
No
Without sharing details, are there any individuals we should screen for overlap to ensure safety within our home?
Yes
No

If yes, staff will follow up verbally.

(No requirement to write trafficker names in the form.)

SECTION 3: Health & Wellness

Have you ever been diagnosed with a mental health condition?
Yes
No
Prefer not to answer

SECTION 4: Substance Use & Stabilization

SafeHope operates on a harm reduction framework. We do not require abstinence prior to intake; however, we assess safety and stabilization needs.

Do you currently use alcohol, cannabis, prescription medication outside prescribed use, or other substances?
Yes
No
Have you used substances in the past 24 hours?
Yes
No

If withdrawal management is required, we may coordinate hospital or detox support prior to intake.

SECTION 5: Recovery Readiness & Program Fit


SafeHope is a structured, long-term recovery program. Residents are expected to participate in:

• Weekly counselling • Group programming • Life skills development • Community living expectations • Confidentiality agreements

Please reflect:

Are you willing to participate in communal living guidelines?
Yes
No

SECTION 6: Community Living Assessment

SECTION 7: Legal & External Factors

SECTION 8: Cultural & Identity Supports

SECTION 9: Support Network

SECTION 10: Additional Information

Participant Acknowledgment:

I understand that SafeHope Home is a structured recovery program with communal living expectations. I understand that intake decisions are based on safety, readiness, and program fit.

Date
Year
Month
Day
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