Sober Living Referral Form

1. Referral Source Information

Your Name:

Phone Number:
Email Address:
Preferred Method of Contact:
☐ Phone ☐ Email

2. Referred Individual Information

Full Name:

Date of Birth:
Phone Number:
Email Address (if available):
Current Location (City/State):
Is the individual aware of this referral?
☐ Yes ☐ No

3. Recovery & Treatment Background

Primary Substance(s) of Use:

☐ Alcohol
☐ Opioids
☐ Methamphetamine
☐ Cocaine
☐ Marijuana
☐ Other: ___________________________
Date of Last Use (if known):
Recent Treatment History:
☐ Detox
☐ Residential Treatment
☐ PHP / IOP
☐ Outpatient
☐ None
☐ Other: ___________________________

Name of Most Recent Treatment Facility (if applicable):
4. Sober Living Needs

Desired Move-In Date:

Length of Stay Expected:
☐ 30 days ☐ 60 days ☐ 90+ days ☐ Unsure
Gender-Specific Housing Needed:
☐ Male ☐ Female 
Ability to Pay Rent:
☐ Yes ☐ Partial ☐ No ☐ Unknown
Employment Status:
☐ Employed ☐ Seeking Employment ☐ Unemployed ☐ Student


5. Legal & Behavioral Considerations
Current Legal Issues (if any):
☐ Probation ☐ Parole ☐ Pending Charges ☐ None
History of Violence or Sexual Offenses:
☐ Yes ☐ No
(If yes, please explain):

6. Additional Information

Please share any information that may help us determine appropriate placement or support needs:

7. Consent & Acknowledgment

I confirm that the information provided is accurate to the best of my knowledge and that I have permission (when applicable) to submit this referral.

Name: ____________________________
Signature: ________________________
Date: _____________________________