Resident Intake Form — White Lily Living

1

Personal Information

First Name *

Last Name *

Date of Birth *

Phone Number *

Email Address

Emergency Contact

Emergency Contact Name *

Relationship *

Emergency Contact Phone *

2

Substance Use History

Please answer as honestly as possible. This information helps us provide the best support.

Primary Substance *

Other Substances Used

Years of Active Use *

Date of Last Use *

Have you been in treatment before? *

Are you currently in a treatment program?

3

Recovery & Sobriety

Sobriety Start Date

Longest Period of Sobriety

Have you experienced a relapse? *

Sponsor / Mentor Name

Sponsor / Mentor Phone

4

Mental Health

This information helps us ensure we can meet your needs and connect you with appropriate support.

Do you have a mental health diagnosis? *

Are you currently taking medications?

Are you currently seeing a therapist or counselor?

5

Legal Background

A criminal history does not automatically disqualify you. Please answer honestly.

Do you have any pending legal issues? *

Are you currently on probation or parole? *

6

Housing & Employment

Current Living Situation *

Employment Status *

Source of Income

Are you able to pay weekly / monthly rent? *

7

House Rules & Commitment

All residents are expected to agree to the following. Please check each box to confirm.

I am committed to maintaining sobriety and will not use drugs or alcohol on the premises or while residing at White Lily Living.

I agree to submit to random drug and alcohol testing at any time as requested by staff.

I agree to attend required house meetings, recovery meetings, and any programming as directed.

I agree to participate in household chores and maintain a clean, respectful living environment.

I agree to follow all house rules and understand that violations may result in discharge from the program.

8

About You

Help us get to know you better.

Why are you applying to White Lily Living? *

What are your goals for your time here? *

How did you hear about us?

Is there anything else you would like us to know?

9

Text Message Communications

I agree to receive text messages from White Lily Living at the phone number provided above. Message frequency varies and will include application updates, appointment reminders, and program information. *

I do not wish to receive text messages from White Lily Living.

Message and data rates may apply. Reply STOP to opt out or HELP for assistance at any time. We never share your mobile opt-in information with any third parties. See our Privacy Policy for details.

Please select your text message preference to submit.