Your Recovery Journey Starts HereComplete the application form below completely to begin your journey. Admission Application "*" indicates required fields Step 1 of 7 - Contact Info 14% Contact InformationClient Name* First Last Date of Birth*Phone ContactOkay to leave message?Select OneYesNoHousing Status* I am currently homeless I live in a home Address* Street Address City State / Province / Region ZIP / Postal Code GenderSelect OneFemaleMaleTransgenerNon-binaryPreferred PronounsSelect OneHe/HimShe/HerThey/ThemOtherRace / EthnicitySelect OneBlack / African AmericanHispanic / LatinoAsian / Pacific IslanderCaucasianBiracialRather not answerEmployment Status*Select OneFull TimePart TimeStudentDisabledUnemployedMain source of income / support?*Preferred Move-in Date MM slash DD slash YYYY Substance Use InformationList all substances in your system*List substances of concern / problem*Last date of use* MM slash DD slash YYYY How much did you use?*How often is the use?*Select OneDaily4-5 days/week1-3 days/week1-3 days/monthPrimary mode of use*Select OneIVNasalSmokeOralHave you ever been hospitalized for detox? Yes No Number of Detox Programs*Between Which Years?*Drugs Needing Detoxed?*Have you ever overdosed?* Yes No How many times?*Between Which Years?*How were the drugs taken?*Select OneIVNasalSmokeOralDate of your most recent overdose* MM slash DD slash YYYY Involving which drugs?*Have you ever been hospitalized due to overdose?* Yes No How many times?*Have you received a Narcan reversal?* Yes No How many times?* Medical InformationDo you have any current medical conditions, illnesses, or chronic health problems?* Yes No Provide details of your current medical conditions*Are you receiving treatment for the above listed medical issues?* Yes No Please provide the doctor / office that provides your medical care*Are you currently in need of medical attention for wound care and/or MRSA?* Yes No Have you been diagnosed with any disabilities?* Yes No Provide details*List any needed items or devices to support functioning*Do you require ambulatory services?* Yes No Do you require oxygen?* Yes No Can you walk upstairs?* Yes No Do you have a history of seizures and/or seizure disorder?* Yes No What is your frequency of seizures?*When was your last seizure event?*Was your seizure drug related?* Yes No Which drugs were involved?*Do you have allergies to medications, food, dyes, materials, etc* Yes No Please list allergies*Are you currently being prescribed MAT for addiction treatment?* Yes No Where are you receiving treatment?*How long have you been receiving treatment?*Which medication are you receiving?*List medication and dosage (mg)Do you have an authorized release signed?* Yes No Have you ever been prescribed MAT for addiction treatment in the past?* Yes No When and for how long?*Where did you receive treatment?*Which medication did you receive?*List medication and dosage (mg) Mental Health InformationHave you been diagnosed with any mental health disorders?* Yes No Please list*Do you have a psychiatrist?* Yes No Provider name and office*Have you ever been hospitalized for mental crisis, suicidal thoughts, and/or attempts?* Yes No How many hospitalizations?*Between which years?*Most recent hospitalization?*Do you have a history of self-injury and/or cutting behavior?* Yes No When was the last occurance?*List current prescription medications for medical and/or mental health:* Treatment EngagePrevious attempts at treatment?* Yes No Total Number of Attempts*Check all that apply* Inpatient Outpatient Last treatment program name and when attended*Are you enrolled in other community and/or legal programs?* Yes No (ex: probation, accountability court, DRC, DFCS, recovery community organizations, etc.)Please list*What are your motivating factors for seeking recovery and treatment?* Legal InformationHave you ever been arrested?* Yes No How many times?*Between which years?*Are you on probation or parole?* Yes No What County?*Officer name and phone*What charges?*Have you ever or are you currently required to register under the sex offender registry* Yes No Last arrest?*Charges*Are you currently on probation or parole?* Yes No What kind of charges*Select OneMisdemeanorFelonyUS / FederalWhich county / counties?*Are you pending charges right now and awaiting court proceedings?* Yes No Which county / counties?*Do you have any known warrants out for your arrest?* Yes No Which county / counties?* Emergency ContactName First Last PhoneEmail Address Street Address City State / Province / Region ZIP / Postal Code
