Access Foundation - Application Form

 

Access Foundation Logo

Access Foundation Application

Welcome to the Access Foundation Application wizard
Click next to begin!

General

Tell us about yourself
What is your legal first name? Client first name
What is your middle name? Client middle name
What is your legal last name? Client last name
When is your birthdate? Client birthdate
What is your race/ethnicity? Client raceClient ethnicity
What is your gender? Client gender
What is your marital status? Client marital status
Are you a veteran? Client veteran status
Do you want to be sober Text field
If yes, why? Example: To be a good member of my community, and be a better father and husband.
Paragraph
 

Contact Information

How can we reach you?
What is your email address? 
Client email
What phone number can we best reach you at? Client phone
What is Your Home Street Address:Client Address
State:Client State
Zipcode:Client Zip

Occupancy

Where would you like to live

What location are you applying for? Radio buttons

What date do you expect to be admitted? Date

 

What is your estimated length of stay? Client estimated length of stay

Assessment

Tell us how you are doing
What has been your longest period of sobriety? Text field

Do you continue to have cravings or a strong desire to use? Text field

Has your recurring substance use resulted in a failure to fulfill major roles at home, work, or school? Text field

Has continued substance use caused social or interpersonal problems? Text field

Have your important social, occupational, or recreational activities been given up or reduced because of substance use? Text field

Have you been in situations in which substance abuse has put you in physical danger? Text field

Has substance use continued despite having knowledge of persistent physical and psychological problems that may have been likely caused by substance use? Text field

Have you increased the amount of the substance to achieve intoxication or the desired effect and experienced diminished effect with continued use of the same amount? Text field


Contacts

Please give us a few people we can contact in an emerergency

Paragraph


Insurance

In the event you need any medical or dental care, please provide us with your insurance information.
Do you have insurance? Text field
 
 Insurance information is required to submit the application. Please fill out the necessary information below. 
 Insurances
 

Medical History

Tell us about your medical history.
When was your last relapse date? Date
What is your substance(s) of choice?  Client substances of choice
Have you been clinically diagnosed with anything?  Client diagnosis
Do you have any health problem Client health problems
What kind of recovery meetings do you attend? Client kinds of meetings attended
What allergies do you have? Client allergies
 

Have you had any of the following tests?

 
 
Are you currently in withdrawal? Text field
 
 
Do you have any issues with mobility? Text field
 
 

Medications

List the medications you are currently prescribed.
 Paragraph

Treatment Centers

Tell us about any treatment centers you've previously been admitted into. 

Paragraph

 

Suicide Screening

Do you have suicidal tendencies? Text field
Do you currently wish to be dead? Text field

Do you have non-specific suicidal thoughts? Text field

Active suicidal ideation? Text field

Have you had any recent suicide attempts in the last six months? Text field


Client Referral Source

 
Who referred you to us? Text field
Can you provide us with the name of the person who referred you? Text field
 

Sober Living History

Tell us about any sober living you've previously been admitted into. 
SoberLivingHistory

Employment

Tell us about your employment status. Text field
If you're currently unemployed, select "unemployed" under "type."  

Education

Tell us about your education status. EducationHistory

Living Arrangement

Tell us about your living arrangements before moving into this facility 

LivingArrangementHistory
 

Criminal Background

Tell us about your criminal history. Criminal History

Felon Have you ever been convicted of a violent crime? Text field

Have you ever been convicted of a sexual crime? Text field
 

Federal Anti-Drug Abuse Act

I realize that the recovery house to which I am applying for residency has been established in compliance with the conditions of § 2036 of the Federal Anit-Drug Abuse Act of 1998, P.L. 100-690, as amended, which provides that federal money loaned to start the house requires the house residents to (A) prohibit all residents from using any alcohol or illegal drugs, (B) expel any resident who violates such prohibition, (C) equally share of household expenses including the monthly lease payment, among all residents, and (D) utilize democratic decision making within the group including inclusion in and expulsion from the group. In accepting these terms, the applicant excludes himself from the regular due process afforded by local landlord-tenant laws.

Agreement

I certify the information I've given above is true to the best of my knowledge. I understand that if I have given any false information, I could be dismissed from Access Foundation Recovery Residences and have my funds forfeited. I understand no onsite clinical treatment services will be provided. Supportive services will be referred to community agencies. A community resource binder will be provided for review in each home.  No transportation is provided. Funding for basic toiletries, bedding and linens, laundry, and other essential household items will be available to each house to budget for items needed based on paid-in-full monthly rent. You are responsible for all your shopping for and your preparation of meals. I acknowledge Access Foundation doesn't accept insurance as payment and doesn't bill insurance for any services. I recognize and respect all program rules, client rights, grievance policy, critical Incident & intervention reports, and discharge documentation. Acceptance of any application requires a majority vote from current tenants based on interviews and information provided. I agree to pay rent on time; if not, I will pay a late fee. No deposit refunds will be given. I consent to drug or alcohol testing at any time by management, the house leadership team, or any tenant in the home. I agree that I can be evicted for non-compliance to the rules at any time and will forfeit any monies paid.

Submission

I have read all the material on this application form, including the limitations set forth above in the Federal Anti-Drug Abuse Act of 1998. I have also answered each question honestly and want to achieve a comfortable recovery from alcoholism and/or drug addiction without relapse.  By continuing, you agree that clicking the Submit button represents your electronic signature and is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.

 Signature
Date Date