top of page

Start Your Journey

​

Taking the first step toward stable housing starts here. Please complete the intake form below with as much information as possible. Our team will review your submission and contact you to discuss your housing needs, answer questions, and guide you through the next steps.

Lily Monarch Project
Pre-Admission Intake & Assessment

  1. Applicant Information

Date of Birth
Month
Day
Year
Gender
Male
Female
Do you have Medicare or Medicaid?

  1. Children & Parenting Responsibilities

Do you have children?
Yes
No
Do you currently have custody?
Yes
No
Shared

  1. Referral & Current Situation

  1. Substance Use History

Substances used - check all that apply
Substances used - check all that apply

  1. Medication-Assisted Treatment (MAT)

Are you currently receiving medication-assisted treatment (MAT)?
Yes
No
Suboxone / buprenorphine
Yes
No
Methadone
Yes
No

  1. Mental Health History

Have you ever been diagnosed with or treated for a mental health condition?
Yes
No

  1. Education, Employment, Income & Transportation

Currently employed?
Yes
No
Can you meet Lilly Monarch Project deposit/program fee requirements?
Yes
No
Need help

  1. Housing & Program Readiness

Are you willing to live in a substance-free environment?
Yes
No
Are you willing to follow house rules, curfew, chores, meetings, and accountability?
Yes
No
Are you willing to participate in developing and working toward 30-day goals?
Yes
No

  1. Applicant Acknowledgment

I certify that the information I have provided is true and complete to the best of my knowledge. I understand that completion of this form does not guarantee admission and that additional information may be requested as part of the assessment and admission process.

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
bottom of page