Structured Housing. Stronger Futures. Lasting Freedom

GUIDE Residential provides structured transitional living for individuals working toward stability, independence, and a successful next chapter.

Serving Customers in Rowan County & Surrounding Areas

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(336) 543-8111

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GUIDE Transition Program

New Resident Intake Form

Guide Recovery New Resident Intake Form

New Resident Intake Form

Confidential screening form to help determine recovery housing fit.
Purpose: This form helps determine whether Guide Recovery is a safe and appropriate fit for your recovery housing needs. Submission does not guarantee acceptance.

Privacy Notice

We ask for sensitive information on this form, including details about substance use, health, and legal history. Here is exactly what happens to it.

Why we ask

We use your answers only to decide whether Guide Recovery is a safe and appropriate fit for you, to plan your move-in, and to coordinate care with people you specifically authorize below. We do not sell your information, and we do not use it for advertising.

How it is protected

  • Your answers travel to us over an encrypted connection and are stored in encrypted form.
  • Only trained intake staff who need it for admissions decisions can open your submission. Access is logged.
  • Records about substance use disorder treatment carry federal confidentiality protections under 42 CFR Part 2, which are stricter than most health privacy rules. In general, we cannot confirm to anyone that you applied, or share what you told us, without your written permission.

Questions that appear as you answer

Some follow-up questions only appear once an earlier answer makes them relevant. If a question is hidden, nothing is stored for it. You will never be asked for detail we do not need.

Resident Information

The county you currently live in, or the county you are being released or discharged from.
Someone we may contact in a medical emergency. We will not tell them you applied unless you authorize it below.

How to Reach You

If you say no, we will only try to reach you by live call or through your referral agency.

Referral Information

Insurance & Benefits

Coverage is not required to apply. We ask so we can help connect you to services you may already qualify for.
Optional. You may leave this blank and give it to staff later if you are accepted.

Recovery Information

Legal & Supervision

We ask because some restrictions affect which properties we can legally place you in.

Housing Need

Readiness & Responsibility

Health & Safety

Medication-assisted recovery is welcome here. Being prescribed buprenorphine, methadone, naltrexone, or a similar medication does not disqualify you from Guide Recovery housing. We ask only so we can support your treatment plan and follow safe medication storage practices in the house.
Check anything that applies. We will follow up to talk through what we can arrange. Asking for an accommodation will not count against your application.
Please read before you answer this question

Answering yes here does not get you immediate help. This form is not monitored, and no one will see your answer until a staff member opens it, which may take one or more business days. Please reach out now instead:

  • Call or text 988 — Suicide & Crisis Lifeline. Free, confidential, 24/7. Chat at 988lifeline.org/chat
  • Call 911 if you or someone else is in immediate danger
  • Text HELLO to 741741 — Crisis Text Line, 24/7
  • Veterans: call 988 and press 1

You can still tell us here so we can support you once we connect. Answering honestly will not automatically disqualify you.

Fit for Guide Recovery

Permission to Coordinate

Coordinating with the people already working with you helps us plan a safe move-in. This permission is optional, and you can say no and still be considered.

What we would share: that you applied to Guide Recovery, your move-in date and status, and only the details needed to plan housing and continued care. Purpose: to confirm referral details, coordinate discharge and move-in timing, verify supervision requirements, and support your treatment plan. Duration: this permission expires [INSERT NUMBER] days from the date you sign, or when you withdraw it, whichever comes first.

for Guide Recovery to exchange the information described above with the parties I checked. I understand this is voluntary, that I may withdraw it at any time in writing, and that withdrawing will not undo sharing that already happened. I understand Guide Recovery will ask me to sign a separate, more detailed release before any records are exchanged.

Agreement

By submitting this form, I understand that completion does not guarantee acceptance into Guide Recovery housing. I understand that Guide Recovery will review my information to determine whether the program is a safe and appropriate fit.
above and I understand how my information will be stored, used, and protected.
and that I should call or text 988, or call 911, if I need help right away.
to the best of my knowledge.

Your answers are sent over an encrypted connection and stored in encrypted form. Only trained intake staff can view them. This confidential screening form helps determine whether the GUIDE Transition Program is a safe and appropriate residential placement. Submission does not guarantee acceptance.

GUIDE RECOVERY | GPS: Goal • Plan • System | We reroute – we don’t tap out.

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