Assessment

First Name*

Middle Name*

Last Name*

Birthdate*

Do you have ID?*

No ID

Partial ID

All ID

Do you have a high school diploma or GED?*

Graduate/GED

Do you have a serious or chronic health condition?*

Yes

Do you have a learning disability?*

Yes

Can you climb steps and perform hygiene practices independently?*

Need Assistance

Yes

Do you have a mental health condition?*

Yes

Are you seeing a doctor for your mental health?*

Yes

Are you taking all your prescribed medication for your mental health?*

Partial

Yes

Do you substance use disorder?*

Yes

What do you feel like well help you with your substance use problem?*

I am not ready to make any changes at this time.

I am thinking about making changes but have not decided what to do.

I want to reduce or better manage my substance use.

I want to stop using substances and am interested in treatment or recovery support.

I am currently working on my recovery and want to continue maintaining my progress.

Question does not apply to me

What steps do you feel are necessary for your recovery?*

I'm not sure what will help me right now.

I feel like getting stable employment and secure housing are the most important steps I need to take in order to support my recovery.

My own motivation and commitment to change.

Support from family, friends, or other positive relationships.

Time alone hasn’t been working for me, and I realize I need to fully commit to my recovery by participating in classes and surrounding myself with others who are working toward the same goal.

Question does not apply to me

Are you currently on Suboxone*

Yes (Do not have a valid prescription and taper plan from physician)

Yes (Have a valid prescription and taper plan from physician)

How many times have you been admitted to treatment for substance use?*

3 or more times

2 times

1 time

None

Can you pass a drug screen?*

Not Sure

Yes

Are you currently incarcerated?*

Prison

Jail

What types of legal charges do you currently have or have had in the past?*

Sexual charges

Severe felony charges (e.g., armed robbery, aggravated assault, homicide/murder, or multiple violent felonies)

Serious felony or violent charges (e.g., burglary, assault, battery, intimidation).

Moderate misdemeanor or non-violent charges (e.g., theft, possession of controlled substances, trespassing).

Minor misdemeanor charges only (e.g., traffic offenses, minor possession, disorderly conduct).

No criminal charges.

What is your verified residence at this time? *

Out of State

Other Indiana County

Henry, Rush, or Fayette County

What specifically about our facility made you choose us over other sober living options?*

I did not have a specific reason for choosing this facility.

The location, cost, or availability made it the best option for me.

I was referred here or heard positive things about the program from others.

I was looking for a structured recovery program with accountability, life-skills development, and peer support.

I specifically chose this facility because I want a Christ-centered recovery program that combines faith, accountability, fellowship, and personal growth.

What are your goals while staying at the Guest House?*

I am not sure what my goals are at this time.

To have a safe place to stay while I figure out my next steps.

To maintain sobriety, improve my daily routine, and begin rebuilding my life.

To strengthen my recovery, obtain employment, secure stable housing, and develop healthy relationships.

To fully commit to my recovery by growing spiritually, building a strong support network, developing life skills, achieving stability, and preparing for independent living

Desired program choice?*

30 Day Emergency

1 Year Work & Save Program (Must be employed full-time before accepted)

1 Year Genesis Recovery

I understand I must stay on the facility property the first 30 days of stay with exception of verified job searches or verified medical and correctional appointments.*

Yes

I understand that nicotine pouches and vapes are prohibited on your facility.*

Yes

I understand that your facility is a Christ-centered recovery community and that all your programming is based on that foundation.*

Yes

If accepted, what is desired move in date? *

Contact person*

Contact Phone*

Contact Email

The Guest House

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