Program Applying For

Choose the program you're interested in. Not sure? Pick "Not Sure" and we'll help you choose.

Residential Treatment 30-Day Inpatient — MenA 30-day inpatient program for men seeking a structured clinical foundation for recovery.Recovery Housing MenLong-term sober living with peer support, employment, and accountability.Recovery Housing WomenLong-term sober living for women in a supportive community.Women's IOP with Housing Intensive OutpatientIntensive outpatient treatment with housing support for women.Community Impact Treatment Intensive OutpatientDay or evening intensive outpatient counseling, life skills, and aftercare.SAP / Dept. of Corrections Referral OnlyTherapeutic recovery programs inside KY correctional facilities. Referral only.Not Sure — Help Me ChooseOur admissions team will help you find the right program for your situation.

Contact

Submitted By (optional)

Date Submitted

Phone Number

Email Address

Preferred Contact Method

PhoneTextEmail

Best Time to Contact

Applicant Information

First Name

Middle Name

Last Name

Preferred Name

Date of Birth

Age

Social Security Number (optional)

Current Address

City

State

ZIP Code

County

Demographics

Sex Assigned at Birth

Gender Identity

Pronouns

Preferred Language

Race / Ethnicity

Marital Status

Highest Education Level

Do you have trouble reading or need help understanding written materials?

NoYes

Emergency Contact

Contact Name

Relationship

Phone

Address

Medical History

Primary Care Physician

PCP Phone

Last Physical Exam

COVID-19 Vaccination

Do you have a Psychiatric Advance Directive (PAD)?

NoYes

Are you interested in developing a PAD?

NoYesWould like more information

Medications & Allergies

No current medicationsNo known allergies

List all current medications and supplements below.

Medication / Supplements	Reason	Dosage	Effective?

Mental Health

Symptom Tracking — rate each over the past week (0 = none, 5 = severe)

Symptom	Rating (0–5)
Anxiety / Panic
Depression / Low Motivation
Sleep Disturbances
Flashbacks / Intrusive Memories
Self-Harm Urges

Other diagnosis / notes

Substance Use & Behavioral Health

Primary Reason for Seeking Treatment

Primary Drug of Choice

Secondary Drug

Substance use history — fill in what applies.

Substance	Amount of Use	Method of Use	Date of Last Use	Age of First Use	Age of Regular Use	Withdrawal / Cravings
Alcohol
Cannabis
Depressants
Hallucinogens
Inhalants
Nicotine
Opioids
Over-the-Counter
Prescription Drugs
Stimulants
Other

Overdose History

Sobriety History

Treatment History

List prior treatment episodes below.

Treatment Issue	Provider & Location	Dates Attended	Type of Facility	Completed Program?

Strengths & Goals

Strength #1

Strength #2

Strength #3

Support System

Why are you seeking treatment?

Recovery Goal

Required Documents

Upload any of the following you have available (optional but helpful).

Government ID

Insurance Card

Medication List

Referral Documents

Court Orders (if applicable)

Probation/Parole Paperwork (if applicable)

Consent

Submission Information

Annie Brookbank
Admissions Coordinator
Admissions@shepherdshouseinc.com
Fax: 859-209-2964
Phone: 859-447-4020

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