Applicants Name
Applicants Email
Applicants Phone
Date of Birth
Clean/Sober Date
Insurance Information
Are you currently in treatment? If so what is the name of the treatment center, your counselor's name and email address, and projected discharge date?
Are you currently incarcerated? If so where are you located and what is the name and number of your case manager?
If you are not in treatment or incarcerated please explain your situation.
If someone is helping you fill out this application and you would like to leave a contact name and number please list that information here.
What medications are you prescribed and taking?
Are you on suboxone, methadone, or Vivitrol maintenance? If so who is your prescribing doctor and what is your current dose?
Do you have any allergies? if so what are you allergic to?
Do you have any mental health diagnosis? If so what are they?
Is your primary concern about substance use or mental health?
What do you think your next step is for your recovery plan?
What type of aftercare options are you seeking with us?
How do you plan on paying?
How willing are you to do whatever it takes to keep your recovery first?
Where have you lived in the past 2 years? Do you currently have a physical ID or driver's license? If so which county are you a resident of according to that ID?
What are your drugs of choice?
Are you currently on Parole or Probation? If so please provide the county, agent's name, and number in which you are on probation or parole.
Have you ever been convicted of a felony or misdemeanor? If so, please explain
Have you been accused of or convicted of any sex offense? If so, please explain
