Monarch Sober Living Homes Admission Assessment

Please fill out the following information honestly and to the best of your ability. This is required for our application process and will be considered regarding admission into our program.
  • (xx/xx/xxxx)
  • This includes prescription or street drugs
  • Check all that apply and list specific form or substance
  • Please explain the history of your drug use, form of drug and how used ie. injected, smoked, snorted.
  • Have you ever been professionally diagnosed with any other disorder? Check all that apply
  • Please explain the history of your co-existing disorder (s), along with approximate diagnosis date.
  • If you have not been in a Treatment Center answer N/A
  • If yes, where and how long?
  • If yes, How many?
  • If yes, how long?
  • If yes, where?
  • If yes, do you have insurance?
  • If yes, how many and what are their ages?
  • If no, where does your family live?
  • Please provide Name and Telephone numbers
  • Pending or Current Charges ( Answer none if not applicable)
  • Answer none if not applicable
  • Answer none if not applicable
  • Answer none if not applicable
  • Make sure you list ALL medication you are currently taking. Medication Name, Dosage (mg), Reason for Taking
  • If you have Health Insurance please type in the name of provider - If not, Type "None"
  • * I warrant the truthfulness of the information provided in this application. Please type your legal first and last name.

© Monarch Sober Living Homes – Assessment form (Updated 7-19-2018)