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Pre-Admission Questionnaire

This short questionnaire helps us determine whether Anchor House Recovery is an appropriate fit for your current needs. Completing this questionnaire does not guarantee admission.

Personal Information

Please Answer Honestly

1. Are you currently sober from alcohol and non-prescribed drugs?
2

What substances are you currently in recovery from?

3

When did you last use alcohol or non-prescribed drugs?

4. Are you willing to remain completely drug- and alcohol-free while living at Anchor House?
5. Are you willing to participate in random drug and alcohol testing, including testing up to twice per week?
6. Are you currently experiencing withdrawal or do you need detoxification or medical supervision to remain sober?
7. Are you currently receiving substance-use or mental-health treatment?
8. Do you currently have any medical, mental-health, behavioral, or other support needs that could make it difficult for you to live safely and independently in a sober-living home?
9. Have you had any recent thoughts or actions involving suicide, self-harm, or harming another person?
10. Do you have any current criminal charges, probation/parole requirements, or criminal history that we should review as part of determining whether our residence can safely meet your needs?
11. Are you willing and able to follow Anchor House rules, including curfew, chores, respectful behavior, no violence or threats, no drugs or alcohol, and no unauthorized guests?
12. Are you able to independently manage your daily needs, including medications, personal hygiene, meals, appointments, and transportation?
13. Can you currently afford the monthly residence fee and required move-in costs?

Preferred room:

14

Why do you want to live at Anchor House, and what are you hoping to accomplish while you are here?

Applicant Acknowledgment

I understand that Anchor House Recovery is a sober-living/recovery residence and is not a detoxification facility, hospital, or clinical treatment program. I understand that my answers will be reviewed to determine whether Anchor House can appropriately meet my housing and recovery-support needs. I certify that the information I provided is accurate to the best of my knowledge.