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Live-In Recovery Program – Intake & Referral Form

Thank you for your interest in SafeHope Home. This form helps determine program fit and safety. You may skip any question that feels overwhelming. Completing this form does not guarantee admission.

1. Contact Information

Preferred Contact Method
Text
Call
Email

2: 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
Is anyone currently looking for you or actively trying to contact you in a way that makes you feel unsafe?
Yes
No

3. Exploitation & Safety Screening

Are you seeking support related to experiences of exploitation or trafficking?
Yes
No

4: Health & Wellness

Are you connected to a mental health provider?
Yes
No
Prefer not to answer

5: Substance Use & Treatment Readiness

SafeHope Home is an abstinence-based live-in recovery program.

All residents must be substance-free prior to admission. Individuals who are currently using substances will be required to complete a treatment program before intake.

Do you currently use any substances?
Yes
No
If needed, are you willing to attend treatment prior to admission?
Yes
No

6: Legal & External Factors


7: Cultural & Identity Supports (Optional)

8: Support Network

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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