Intake Application — Covenant Life Services

Personal Background & Contact Information

First name *

Last name *

Email address *

Phone number *

Date of birth

Current address

City

State

Zip

Emergency Contact

Name

Phone

Relationship

Recovery History & Treatment Details

Sobriety date (or approximate)

Primary substance

Other substances used (if applicable)

Treatment history

Treatment facility name

Completion date (approx)

Currently in a program?

Program details (if active)

Health Information

Mental health diagnosis (if any)

Current medications

Attending AA/NA meetings?

How often?

Financial Readiness & Employment

Employment status

Employer name (if employed)

Estimated monthly income

How will you pay program fees?

Do you have health insurance?

Insurance provider (if applicable)

Background

Any felony convictions?

If yes, please briefly describe

Sex offense history?

Valid driver's license?

Do you have a vehicle?

House Rules & Expectations

Please read each expectation carefully and check the box to confirm your understanding and agreement. All boxes must be checked to proceed.

General House Rules

I understand that all residents must maintain complete sobriety from drugs and alcohol while residing in any Covenant Life Services home. Possession or use of any substance on premises is grounds for immediate dismissal.

Drug & Alcohol Testing

I consent to random and scheduled drug and alcohol testing, including breathalyzer and urinalysis, as a condition of my residency.

Weekly House Meetings

I commit to attending all scheduled weekly house meetings. Meetings are mandatory and essential to maintaining community accountability.

Curfew

I acknowledge and agree to abide by the house curfew. Curfew times will be communicated at move-in and may vary by home. Repeated violations may result in removal.

Employment / Productive Activity

I agree to maintain employment, actively seek employment, or be enrolled in an approved program (school, vocational training, volunteer work) during my residency.

Shared Responsibilities

I agree to participate in assigned household chores and maintain clean personal and common living spaces.

Scheduling & Final Details

Preferred move-in date

Residence needed for

Preferred area

How did you hear about us?

Preferred contact method

Best time to reach you

Anything else you'd like us to know?

Apply for Sober Living

Personal Background & Contact Information

Recovery History & Treatment Details

Financial Readiness & Employment

House Rules & Expectations

Scheduling & Final Details

Application Received