TUTTA REGALITA NETWORK LLC • 1805 E Mia Ln, Gilbert, AZ 85298 • (602) 473-0339 • housing@tuttaregalitanetwork.com • CONFIDENTIAL
TUTTA REGALITA NETWORK LLC
RESIDENT INTAKE PACKET
Transitional Housing • Recovery Support Services • Behavioral Health Programming
1805 E Mia Ln, Gilbert, AZ 85298 • (602) 473-0339
housing@tuttaregalitanetwork.com • admin@tuttaregalitanetwork.com
INTAKE IDENTIFICATION
Intake Date:06/04/2026
Intake Time:10:30 AM
Staff Completing Intake:Jordan Avery, LMSW
Staff Title / Role:Intake Clinician
Resident Full Legal Name:Doe, John Michael
Date of Birth:03/14/1989
Age:37
Social Security Number (last 4 only):4821
Gender Identity:Male
Facility Address (same as TRN):1805 E Mia Ln, Gilbert, AZ 85298
Assigned Bed Number:B-4
Move-In Date:06/05/2026
PACKET CONTENTS — TABLE OF SECTIONS
Page 1Cover Page — Intake Identification
Page 2Section 1 — Resident Demographics & Personal Information
Page 3Section 2 — Insurance, Financial & Benefits Information
Page 4Section 3 — Emergency Contacts & Support System
Page 5Section 4 — Referral & Housing History
Page 6Section 5 — Presenting Problem & Chief Complaint
Page 7Section 6 — Psychiatric & Mental Health History
Page 8Section 7 — Substance Use History
Page 9Section 8 — Medical History & Current Medications
Page 10Section 9 — Mental Status Examination
Page 11Section 10 — Risk Assessment & Safety Planning
Page 12Section 11 — Treatment Goals & Aftercare Plan
Page 13Section 12 — House Rules Acknowledgment & Consent
Page 14Section 13 — Signatures & Authorizations
Instructions for Completing This Packet
1.All sections must be completed in full. Write N/A if a question does not apply — do not leave any field blank.
2.This packet must be completed on or before the day of move-in. Incomplete packets will delay enrollment.
3.Staff completes Sections 1–11. The resident completes and signs Sections 12–13 in the presence of staff.
4.All information is strictly confidential and protected under HIPAA. This document is for authorized use only.
5.Attach all supporting documents: photo ID, insurance card, discharge summary, psychiatric evaluation, TB test.
Resident Intake PacketCONFIDENTIAL — Protected Health InformationPage 1 of 14
TUTTA REGALITA NETWORK LLC — RESIDENT INTAKE PACKETSection 1 — DemographicsPage 2 of 14
SECTION 1 — RESIDENT DEMOGRAPHICS & PERSONAL INFORMATION
Full Legal Name (Last, First, Middle):Doe, John Michael
Date of Birth:03/14/1989
Age:37
Gender Identity:Male
Preferred Name / Nickname:John
Pronouns:he/him
Race:White
Ethnicity:Non-Hispanic
Primary Language:English
Interpreter Needed:YesNo
Current Address (prior to move-in):742 W Glendale Ave
City:Phoenix
State / Zip:AZ / 85021
Phone Number:(602) 555-0147
Email Address:jdoe@example.com
Marital Status:Single
Number of Children:2
Children living with resident?YesNo
Custody Status:Shared w/ mother
Identification Documents
Arizona State ID / Driver's License No.:D08123456
Expiration Date:03/2028
Social Security Number: 
SSN Card on file?YesNo
Birth Certificate on file?YesNo
Passport?YesNoN/A
Other ID documents (specify): 
Education & Employment
Highest Education Level:Some High SchoolGEDHigh School DiplomaSome CollegeAssociate'sBachelor's+
Employment Status:Unemployed
Occupation / Field:Warehouse
Current Employer (if any): 
Employer Phone: 
Work History (most recent): 
Benefits & Income
Benefits received:EBT / SNAPSSISSDIGAUnemploymentNone
EBT Card in possession?YesNo
Monthly income (approx.):$914
Other income sources: 
Cultural & Religious Background
Cultural background / Tribal affiliation: 
Tribal enrollment?YesNo
Religious / Spiritual affiliation:None
Special cultural needs: 
Resident Intake PacketCONFIDENTIAL — Protected Health InformationPage 2 of 14
TUTTA REGALITA NETWORK LLC — RESIDENT INTAKE PACKETSection 2 — Insurance & FinancialPage 3 of 14
SECTION 2 — INSURANCE & FINANCIAL INFORMATION
Primary Insurance
Insurance Plan / Carrier: 
Plan Type: 
Member ID Number: 
Group Number: 
Insurance Phone Number: 
Authorization Number: 
Authorization Contact Name: 
Authorization Phone: 
Effective Date of Coverage: 
Card in possession?YesNoOrderedLost
Notes on insurance status: 
⚠ Insurance Eligibility Reminder — Verify before completing enrollment
Accepted plans for clinical outpatient programming (Renewed Path LLC): AHCCCS — American Indian Health Plan (AIHP) • BlueCross BlueShield (BCBS) Marketplace • Aetna Marketplace • Cigna Marketplace. AHCCCS Mercy Care: NOT currently accepted.
Secondary Insurance (if applicable)
Insurance Plan / Carrier: 
Member ID Number: 
Authorization Number: 
Auth Contact: 
Notes: 
Medicaid / AHCCCS Details
AHCCCS ID Number: 
AHCCCS Plan / Contractor: 
SMI Designation?YesNo
SMI Clinic (if applicable): 
Case Manager Name: 
Case Manager Agency: 
Case Manager Phone: 
Case Manager Email: 
Next scheduled case manager visit: 
Pharmacy Information
Preferred Pharmacy Name & Address: 
Pharmacy Phone: 
Pharmacy Fax: 
Accepts resident's insurance?YesNoUnknown
Notes: 
Insurance Conversion (if applicable)
Conversion in process?YesNo
Converting from: 
Converting to: 
Target effective date: 
Conversion contact / notes: 
Resident Intake PacketCONFIDENTIAL — Protected Health InformationPage 3 of 14
TUTTA REGALITA NETWORK LLC — RESIDENT INTAKE PACKETSection 3 — Emergency ContactsPage 4 of 14
SECTION 3 — EMERGENCY CONTACTS & SUPPORT SYSTEM
Primary Emergency Contact
Full Name: 
Relationship: 
Phone (Primary): 
Phone (Secondary): 
Address: 
City: 
State / Zip: 
Email: 
Best time to contact: 
Authorized to receive information?YesNo
Secondary Emergency Contact
Full Name: 
Relationship: 
Phone (Primary): 
Phone (Secondary): 
Address: 
Email: 
Authorized to receive information?YesNo
Support System Assessment
Identified support system?YesNoLimited
Describe support system (family, friends, sponsor, community): 
Are there people resident should have NO contact with?YesNo
Names: 
Reason for no contact (restraining order, safety concern, etc.): 
Guardian / Legal Representative (if applicable)
Guardian / Rep Name: 
Relationship: 
Phone: 
Email: 
Power of Attorney on file?YesNo
Type: 
DCS case active?YesNo
DCS Case Number: 
DCS Worker Name & Contact: 
Resident Intake PacketCONFIDENTIAL — Protected Health InformationPage 4 of 14
TUTTA REGALITA NETWORK LLC — RESIDENT INTAKE PACKETSection 4 — Referral & HousingPage 5 of 14
SECTION 4 — REFERRAL SOURCE & HOUSING HISTORY
Referral Information
Referring Facility / Organization: 
Referring Contact Name: 
Title / Role: 
Referring Phone: 
Referring Email: 
Referring Fax: 
Date of Referral: 
Referring Facility Address: 
Discharge Date from Referring Facility: 
Discharge Type: 
Discharging Provider / Physician: 
Reason for referral to TRN: 
Housing History
Housing situation immediately prior to admission:Residential TreatmentGroup HomeHomelessShelterFamily/FriendsOwn home
If Other, describe: 
Length of time at last housing placement: 
Previous sober living / transitional housing?YesNo
How long ago: 
Name of previous transitional housing (if any): 
Reason for leaving previous placement: 
History of eviction?YesNo
Eviction details (if yes): 
Prior Treatment History
Treatment TypeYes / NoHow Many TimesMost Recent Date
Inpatient Psychiatric HospitalizationYesNo
Residential SUD / BHRF ProgramYesNo
Intensive Outpatient Program (IOP)YesNo
Sober Living / Halfway HouseYesNo
Individual Therapy / CounselingYesNoFrequency: Duration:
Resident Intake PacketCONFIDENTIAL — Protected Health InformationPage 5 of 14
TUTTA REGALITA NETWORK LLC — RESIDENT INTAKE PACKETSection 5 — Presenting ProblemPage 6 of 14
SECTION 5 — PRESENTING PROBLEM & CHIEF COMPLAINT
Chief Complaint (Resident's own words — use quotation marks)
"I need a stable, sober place to live so I can get back on my feet."
Presenting Problem — Clinical Summary (Staff completes)
37-year-old male referred from Valley Detox following 7-day medical detox for alcohol and methamphetamine. Reports 12-year history of polysubstance use, recent homelessness, and one prior residential treatment episode. Motivated for transitional housing and outpatient programming.
Functional Impairment Assessment
Activities of Daily Living (ADL)Independent Needs assistance Dependent
Occupational / Work FunctioningIntact Mildly impaired Significantly impaired
Interpersonal / Social FunctioningIntact Mildly impaired Significantly impaired
Psychological / Emotional FunctioningStable Mildly impaired Significantly impaired
Ability to maintain sobriety without supportAble Struggles Unable without structure
Motivation for Treatment
Voluntary admission?YesNoCourt-ordered
Motivation level:Highly motivatedMotivatedAmbivalentResistant
Resident's stated reason for seeking housing and treatment:Wants stability, employment, and to reconnect with his children.
 
Resident Intake PacketCONFIDENTIAL — Protected Health InformationPage 6 of 14
TUTTA REGALITA NETWORK LLC — RESIDENT INTAKE PACKETSection 6 — Psychiatric HistoryPage 7 of 14
SECTION 6 — PSYCHIATRIC & MENTAL HEALTH HISTORY
Diagnoses
Primary Psychiatric Diagnosis: 
ICD-10 Code: 
Secondary Diagnosis: 
ICD-10 Code: 
Tertiary Diagnosis: 
ICD-10 Code: 
Medical Diagnoses: 
ICD-10 Code(s): 
SMI Designation:YesNoPending eval
SMI Clinic / Program: 
Psychiatric History
Prior psychiatric hospitalizations?YesNo
Number of prior hospitalizations: 
Most recent date: 
Most recent inpatient facility: 
Diagnosis / reason for most recent hospitalization: 
History of suicide attempts?YesNo
Number of attempts: 
Most recent attempt date: 
Method used (most recent): 
History of self-harm (non-suicidal)?YesNo
Self-harm method / description: 
Trauma History
History of trauma or abuse?YesNoDeclined to disclose
Type of trauma (check all that apply):Physical abuseSexual abuseEmotional/psychologicalDomestic violenceChildhood traumaPTSD
Additional trauma notes (if resident consents to share): 
Current Psychiatric Providers
Psychiatrist Name: 
Phone: 
Therapist / Counselor Name: 
Phone: 
PCP / Primary Care Physician: 
Phone: 
Last psychiatric appointment: 
Next scheduled appointment: 
Family Psychiatric History
Family history of mental illness (relationship & condition): 
Family history of substance use (specify): 
Resident Intake PacketCONFIDENTIAL — Protected Health InformationPage 7 of 14
TUTTA REGALITA NETWORK LLC — RESIDENT INTAKE PACKETSection 7 — Substance UsePage 8 of 14
SECTION 7 — SUBSTANCE USE HISTORY
Substances used (check all that apply):AlcoholMethamphetamineCocaine/CrackHeroinFentanylMarijuana/THCBenzodiazepinesOther
Primary substance (drug of choice):Methamphetamine
Age of first use:16
Last date of use:05/27/2026
Amount / frequency:Daily
Route of use:Smoked
Duration of use (years):12
SubstanceLast UseAmount / FrequencyRouteYears UsingIn Recovery?
Alcohol
Methamphetamine
Cannabis / THC
Opioids / Heroin / Fentanyl
Cocaine / Crack
Benzodiazepines
Nicotine
Other:
Treatment & Recovery History
Longest period of sobriety: 
When: 
What helped maintain sobriety during that period: 
Triggers for relapse: 
Coping strategies used: 
Currently attending AA/NA?YesNoWilling to start
AA/NA Sponsor?YesNo
Sponsor Name & Phone: 
History of overdose?YesNo
Most recent date & substance: 
Withdrawal history (substance and severity): 
Screening Tools (Staff completes)
AUDIT Score (alcohol):22
DAST-10 Score (drugs):8
CAGE-AID Score: 
ASAM Dimension 1 Score: 
ASAM Level of Care Recommended:3.1
Resident Intake PacketCONFIDENTIAL — Protected Health InformationPage 8 of 14
TUTTA REGALITA NETWORK LLC — RESIDENT INTAKE PACKETSection 8 — Medical & MedicationsPage 9 of 14
SECTION 8 — MEDICAL HISTORY & CURRENT MEDICATIONS
Medical Conditions
Active medical conditions (check all):Diabetes (Type 1)Diabetes (Type 2)HypertensionHeart diseaseHepatitis BHepatitis C
Other medical conditions (specify): 
Allergies (medications, foods, environment): 
TB Test result: 
TB Test date: 
Most recent physical exam date: 
Provider name / facility: 
Surgical & Hospitalization History
Surgeries (type and approximate date): 
Recent medical hospitalizations (past 12 months): 
Current Medications — List all medications brought to facility at intake
#Medication NameDoseFormRouteSchedule / FrequencyIndicationPrescriberCount at Intake
1
2
3
4
5
6
7
8
9
10
Medication Management
Can resident self-administer medications?YesNoWith supervision
Medication compliance history:Fully compliantMostly compliantNon-compliantUnknown
Medication-related concerns or special instructions: 
Staff who counted medications: 
Date / Time of count: 
Resident Intake PacketCONFIDENTIAL — Protected Health InformationPage 9 of 14
TUTTA REGALITA NETWORK LLC — RESIDENT INTAKE PACKETSection 9 — Mental Status ExamPage 10 of 14
SECTION 9 — MENTAL STATUS EXAMINATION (Completed by staff at intake)
AppearanceWell groomedDisheveledAppropriate dressPoor hygieneAge appropriateOther:
BehaviorCooperativeGuardedAgitatedRestlessCalmSuspiciousOther:
SpeechNormal rate/tonePressuredSlowLoudSoftSlurredOther:
Mood (resident's words)EuthymicDepressedAnxiousEuphoricIrritableAngryOther:
AffectFullConstrictedBluntedFlatCongruentIncongruentLabile
Thought ProcessGoal-directedTangentialCircumstantialDisorganizedRacing thoughts
Thought ContentNo SI/HISuicidal ideationHomicidal ideationParanoiaDelusionsOther:
PerceptionsNo hallucinationsAuditory hallucinationsVisual hallucinationsOther:
OrientationPersonPlaceTimeSituationNot fully oriented — specify:
MemoryIntactRecent impairedRemote impairedBoth impaired
Attention / ConcentrationIntactMildly impairedSignificantly impaired
InsightGoodFairPoorAbsent
JudgmentGoodFairPoor
Intelligence EstimateBelow averageAverageAbove average
Motor ActivityNormalHyperactiveSlowedTremorsAkathisiaOther:
Mental Status Summary (Staff narrative)
 
Resident Intake PacketCONFIDENTIAL — Protected Health InformationPage 10 of 14
TUTTA REGALITA NETWORK LLC — RESIDENT INTAKE PACKETSection 10 — Risk AssessmentPage 11 of 14
SECTION 10 — RISK ASSESSMENT & SAFETY PLANNING
Suicidal Ideation Assessment
Current suicidal ideation?NonePassive ideationActive ideationWith planWith intent
History of suicide attempts?YesNo
Number of attempts: 
Most recent date and method: 
Access to means?Yes (specify)No
Means (if yes): 
Overall suicide risk level:NoneLowModerateHighImminent
Self-Harm Assessment
Current self-harm ideation?NoneIdeation onlyRecent behavior
Self-harm method / description: 
Homicidal Ideation Assessment
Current homicidal ideation?NonePassiveActiveWith identified target
Details (if any): 
Violence / Aggression History
History of violent behavior?YesNo
Description (if yes): 
Active restraining orders?YesNo
Details: 
Legal History
Active legal issues?YesNo
Probation or parole?YesNo
Probation / Parole Officer Name & Contact: 
Pending charges / court dates: 
Court-ordered treatment?YesNo
Court order details: 
Safety Plan
Warning signs that a crisis may be developing: 
Internal coping strategies resident will use: 
Crisis contact 1 (name & phone): 
Crisis contact 2 (name & phone): 
Crisis line: 602-222-9444 • National: 988 • Emergency: 911 • Warm Line: 602-347-1100
Resident Intake PacketCONFIDENTIAL — Protected Health InformationPage 11 of 14
TUTTA REGALITA NETWORK LLC — RESIDENT INTAKE PACKETSection 11 — Treatment GoalsPage 12 of 14
SECTION 11 — TREATMENT GOALS & AFTERCARE PLAN
Short-Term Goals (30 Days)
Goal 1: 
Goal 2: 
Goal 3: 
Goal 4: 
Long-Term Goals (60–90 Days)
Goal 1: 
Goal 2: 
Goal 3: 
Goal 4: 
Aftercare & Discharge Plan
Anticipated discharge housing plan: 
Target discharge date: 
Estimated length of stay: 
Outpatient clinical program enrolled?Yes — Renewed Path LLCYes — OtherNoPending insurance
Outpatient program name & address: 
Outpatient program schedule: 
AA/NA participation plan:DailyWeeklyTwice weeklyAs neededNot applicable
Sponsor identified?YesNo
Sponsor Name & Phone: 
Employment / education goals: 
Family reunification goals: 
Additional aftercare plan notes: 
Referrals Made at Intake
ReferralStatusAgency / Contact
Case ManagementReferredAlready assignedDeclined
Psychiatric ServicesReferredAlready assignedDeclined
Primary Care PhysicianReferredAlready assignedDeclined
Employment ServicesReferredDeclinedNot applicable
Legal ServicesReferredDeclinedNot applicable
Resident Intake PacketCONFIDENTIAL — Protected Health InformationPage 12 of 14
TUTTA REGALITA NETWORK LLC — RESIDENT INTAKE PACKETSection 12 — House RulesPage 13 of 14
SECTION 12 — HOUSE RULES ACKNOWLEDGMENT (Resident reads and initials each item)
1
Sobriety Compliance. I understand that I must maintain complete sobriety at all times. No alcohol, illegal drugs, or unprescribed controlled substances are permitted on the premises or in my system.
JD
Initial
2
Curfew. I agree to abide by all curfew requirements as set by TRN staff. I will notify staff in advance if I need to leave the facility and will sign out and in using the Exit & Entrance Log.
JD
Initial
3
Program Participation. I agree to actively participate in all required outpatient programming, group meetings, and individual counseling as scheduled by Tutta Regalita Network LLC and its clinical partners.
JD
Initial
4
Medication Management. I agree to take all prescribed medications as directed. I will not share, sell, or misuse any medications. I understand that medication administration is monitored and recorded by staff.
JD
Initial
5
Respect & Conduct. I agree to treat all staff, residents, and visitors with dignity and respect at all times. Threatening, intimidating, violent, or sexually inappropriate behavior is grounds for immediate discharge.
JD
Initial
6
Property & Cleanliness. I agree to maintain my room and shared spaces in a clean and orderly condition. I will not damage or destroy facility property. I am responsible for the cost of any damages I cause.
JD
Initial
7
Visitors. I understand that visitors must be approved by staff in advance. Unauthorized visitors are not permitted on the premises. Intimate partners may not stay overnight.
Initial
8
Drug Testing. I agree to submit to random urinalysis (UA) and/or breathalyzer testing at any time requested by staff. Refusal to test will be treated as a positive result and may result in discharge.
Initial
9
Weapons. I understand that no weapons of any kind are permitted on the premises at any time. Possession of a weapon is grounds for immediate discharge and may result in law enforcement involvement.
Initial
10
Confidentiality. I agree to respect the privacy and confidentiality of all other residents. I will not share personal information about other residents outside of the facility.
Initial
11
Financial Obligations. I agree to meet all financial obligations to TRN as outlined in my residency agreement, including program fees, rent contributions, and any applicable deposits.
Initial
12
Discharge. I understand that violation of any of the above rules may result in immediate discharge from the program. I agree to vacate the premises immediately if discharged.
Initial
Resident Intake PacketCONFIDENTIAL — Protected Health InformationPage 13 of 14
TUTTA REGALITA NETWORK LLC — RESIDENT INTAKE PACKETSection 13 — SignaturesPage 14 of 14
SECTION 13 — CONSENTS, AUTHORIZATIONS & SIGNATURES

Consent to Treatment & Services

I voluntarily consent to receive transitional housing, recovery support services, and behavioral health programming through Tutta Regalita Network LLC and its clinical partners. I understand that participation in outpatient programming is a condition of my residency. I may withdraw consent at any time.
Resident Signature:John M. Doe
Date:06/04/2026

Consent to Release of Information

I authorize Tutta Regalita Network LLC to share relevant health and program information with my clinical outpatient program partner (Renewed Path LLC), case manager, prescribing physician, insurance carrier, and other treatment providers involved in my care, as necessary for coordination of services.
Resident Signature:
Date:

HIPAA Notice Acknowledgment

I acknowledge that I have received the Notice of Privacy Practices from Tutta Regalita Network LLC. I understand my rights regarding the use and disclosure of my protected health information (PHI) under HIPAA.
Resident Signature:John M. Doe
Date:06/04/2026

Medication Administration Consent

I consent to medication administration oversight by TRN staff as prescribed by my physician. I authorize staff to monitor, record, and coordinate my medications in accordance with my treatment plan and the facility's Medication Administration Record (MAR).
Resident Signature:
Date:

Photo / Video Release

I consent do not consent to the use of my photograph or likeness for TRN program documentation, internal records, and promotional materials. I understand this consent is voluntary.
Resident Signature:
Date:

House Rules Acknowledgment

I have read, understood, and initialed each of the twelve house rules in Section 12 of this packet. I agree to abide by all rules and understand that violations may result in immediate discharge.
Resident Signature:
Date:

Attestation of Accuracy & Completeness

I attest that all information provided in this intake packet is accurate and complete to the best of my knowledge. I understand that false or misleading information may result in immediate termination of services.
Resident Signature:
Date:
Printed Name:John Michael Doe
Staff Signature:
Date:
Staff Title:Intake Clinician
Resident Intake PacketCONFIDENTIAL — Protected Health InformationPage 14 of 14