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(336) 543-8111

Email

Belleair410@gmail.com

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Email

Belleair410@gmail.com

Business Hours

Monday

9:00 AM – 4:30 PM

Tuesday

9:00 AM – 4:30 PM

Wednesday

9:00 AM – 4:30 PM

Thursday

9:00 AM – 4:30 PM

Friday

9:00 AM – 4:30 PM

Saturday

Closed

Sunday

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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.

Resident Information

Full Name

Date of Birth

Phone Number

Email Address

Current Address

Emergency Contact Name & Phone

Recovery Information

Are you currently sober?

Yes No Not Sure / N/A

Date of Last Use

Primary Substance Used

Are you currently in treatment, detox, IOP, or counseling?

Yes No Not Sure / N/A

Do you attend AA, NA, church, support groups, or recovery meetings?

Yes No Not Sure / N/A

What does recovery mean to you right now?

Housing Need

Why are you seeking recovery housing?

Where are you currently living?

Do you have a safe place to stay tonight?

Yes No Not Sure / N/A

Have you lived in sober living or transitional housing before?

Yes No Not Sure / N/A

Are you willing to follow house rules, curfew, drug testing, and accountability expectations?

Yes No Not Sure / N/A

Readiness & Responsibility

Are you currently employed?

Yes No Not Sure / N/A

If not, are you willing to seek employment, training, or education?

Yes No Not Sure / N/A

Do you have valid ID?

Yes No Not Sure / N/A

Do you have transportation?

Yes No Not Sure / N/A

Do you have current legal obligations, probation, or court dates?

Yes No Not Sure / N/A

Are you willing to participate in GPS goal planning: Goal, Plan, System?

Yes No Not Sure / N/A

Health & Safety

Do you have any medical or mental health concerns we should know about?

Are you taking prescribed medication?

Yes No Not Sure / N/A

Do you have any history of violence, threats, or unsafe behavior in a group living setting?

Yes No Not Sure / N/A

Are you currently experiencing thoughts of harming yourself or others?

Yes No Not Sure / N/A

Fit for Guide Recovery

What are your top three goals for the next 90 days?

What support do you need most right now?

Why do you believe Guide Recovery is the right place for you?

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.

Applicant Signature / Typed Name

Date

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

Home
Housing & Support
About
FAQ
Contact

Home
Housing & Support
About
FAQ
Contact

Location

[custom_address]

Business Hours

Monday

9:00 AM – 4:30 PM

Tuesday

9:00 AM – 4:30 PM

Wednesday

9:00 AM – 4:30 PM

Thursday

9:00 AM – 4:30 PM

Friday

9:00 AM – 4:30 PM

Saturday

Closed

Sunday

Closed

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Phone

(336) 543-8111

Email

Belleair410@gmail.com

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