Admission Criteria

EverRise Recovery Services, LLC
Level II Sober Living Program – Application for Admission
Kendrick Major, LCSW, LCAC – Owner/Director
Ph: (317) 289-5253 | Indianapolis, Indiana

SECTION 1 – APPLICANT INFORMATION

First Name

Last Name

Date of Birth:

Current Age:

Social Security Number: (optional)

Gender Identity:

Sexual Orientation:

Phone

Email Address

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Emergency Contact (name, relationship, phone, address)

SECTION 2 – RECOVERY BACKGROUND

Date of Sobriety:

Primary Substance(s) Used:

Length of Addiction:

Last Date of use:

Current or Previous Treatment or Sober Living Experience (where, when, how long)

Current or Previous Sponsor:

Required to Participate by Court, Probation, or Parole?YesNo

Are you currently on probation/parole?YesNo

SECTION 3 – EMPLOYMENT / INCOME

Current Employment Status:

Employer Name:

Employer Phone

Employment Address:

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Weekly Income / Pay Schedule:

Source of Financial Support (if unemployed)

SECTION 4 – MEDICAL INFORMATION

Current Medical Conditions:

Current Medications (dosage, frequency, prescribing doctor)

Allergies:

History suicide ideationYesNo

History self-harming behavior:YesNo

Physical Limitations or Disabilities:

Mental Health Diagnosis (if applicable):

Are you currently under psychiatric care?YesNo

Emergency Medical Provider or Clinic:

SECTION 5 – LEGAL HISTORY

Current Probation/Parole Officer Contact Info:

SECTION 6 – PROGRAM FINANCIAL AGREEMENT

Move-In Fee: $400 due at intake.

Security Deposit: $350 (refundable upon successful program completion).

Monthly Program Fee: $750-$800 or ($188-$200 per week).

Accepted payment methods (Credit Card, Zelle, Cash App, MoneyGram or Money Order).

Family members, Sponsors or other Third-Party entities may call and make housing payment on behalf of the resident as well.

Late payment policy acknowledgment (Outlined Policy Manual & Resident Handbook)

SECTION 7- CASE-MANAGEMENT NEEDS

Need to apply for or obtain:

SECTION 8 – HOUSE RULES & EXPECTATIONS

All Level II sober living rules (attendance, employment, testing, curfew, visitors, chores, meetings participation, etc.) are outlined in the Policy Manual & Resident Handbook prior to admission. Acknowledgment of zero-tolerance policy required.

SECTION 9 ORIENTATION & ACKNOWLEDGMENT

I fully understand that admission is conditional upon compliance with program policies, participation in orientation and engagement in my recovery plan.

SECTION 10 – CONSENT & SIGNATURES

Consent to random drug/alcohol testing. Permission for staff to verify employment/income. Release of limited information to probation, treatment, or referral source, statement of understanding and agreement to abide by house policies

Signature

Eligibility

Process

Application Form