Admissions

Agape House Intake Packet

Please complete every applicable section. Your information helps our team understand your placement and support needs. Completing this form does not guarantee placement.

Before you begin: This form can be completed on a phone or computer. When finished, choose “Print or Save PDF” and send the saved copy to the Agape House admissions team.

1. Applicant information

Full legal namePreferred name Date of birthPhone number Email addressCurrent address California ID / driver’s license numberPreferred language

2. Referral and emergency contact

Referral source / agencyCase worker Case worker phoneCase worker email Emergency contact nameRelationship Emergency contact phoneAlternate phone

3. Placement and recovery information

Requested move-in datePrimary substance(s) Date last usedCurrent recovery program Clean / sober dateSponsor name and phone Treatment, recovery, or reentry goals Previous recovery residences or treatment programs

4. Health and support needs

Primary healthcare providerHealth insurance Current medications, including dosage Medical conditions, allergies, accessibility needs, or other information staff should know Mental health services or support currently received

5. Legal, employment, and financial information

Probation / parole officerOfficer phone Upcoming court dateCounty / department Employment status Employer or school Monthly income / benefitsRent funding source Transportation plan

6. Program readiness

I agree to maintain a substance-free living environment. I agree to random alcohol and drug testing. I agree to attend required recovery meetings and the weekly house meeting. I agree to follow curfew, chore, guest, safety, and house rules. I agree to work toward employment, education, treatment, service, or another approved plan.

7. Applicant acknowledgment

I certify that the information provided is accurate to the best of my knowledge. I understand that Agape House may contact the referral source or case worker to coordinate placement, and that submitting this packet does not guarantee admission.

Applicant signature (type full name)Date

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