Intake Resident Form

**IF YOU ARE HAVING DIFFICULTY COMPLETING THIS FORM, PLEASE CONTACT OUR INTAKE COORDINATOR @ 513-472-9087 FOR ASSISTANCE.

**Before contacting our Intake Coordinator or completing this form, have you read the
FAQ’S on the website and able to comply?

Name

Current Address

City/State Zip Code

Email address

Telephone Number (digits only, no hyphens or spaces)

I am a...(Please Check One)

Potential Resident

Professional

Family Member

Other (Please describe below)

Description (if needed)

How did you hear about us?

Please select from the following: Court, Attorney, Employee, Internet, Friend, Mental Health Provider, Doctor/Therapist, 12-Step Meeting, Social Media? (Which One?)

Additional Questions:

1. How long have you been sober?

2. Are you willing to sign a consent for St. Zachary's Haven to conduct your background check and understand you will be drug tested upon admission, randomly, and post-accident?

Yes

3. Can you remain sober and attend regularly scheduled meetings?

Yes

4. Can you accept and get along peacefully with others living in a communal setting?

Yes

5. Are you able to work, attend classes, prepare your own meals, and attend the scheduled activities?

Yes

6. Are you willing to improve yourself on a daily basis regarding your body, mind and spirit? This includes daily exercise.

Yes

7. Do you understand St. Zachary's Haven is a spiritual and faith-based sober living home? We will provide residents with sober recovery and living by means of nature, healing on a holistic level, working with hands by cultivating the land, tending of farm animals, and sharing work responsibilities within the home.

Yes

8. Are you willing to accept working on a farm, including animal care and gardening? *Please Note: Living on a farm may cause some allergic reactions.

Yes

I hope to be admitted into the program on this date:

Congratulations! You have completed the second step in our process. Once you submit this information, a staff member from our admissions team will review and contact you either by email or phone. If the program is available and you meet the pre-qualifications, a phone interview with our management team will be the next step, followed by a written application and an onsite interview. During this process, we will be asking for more personal information about your situation. Thank you for your interest in St. Zachary's Haven.

3364 US 22 & 3 | Morrow, OH, 45152 | 513-472-9087 |

Email address

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