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 Client middle name Client last name
What is your birthdate? Client birthdate
What is your race/ethnicity? Client race Client ethnicity
What is your gender? Client gender
What is your marital status? Client marital status
Are you a veteran? Client veteran status
Do you have a criminal history? Radio buttons
Explain: Criminal History
Do you want to be sober? Radio buttons
If yes, why?
Paragraph
Contact Information
How can we reach you?
What is your email address? Client email
What is your phone number? Client phone
What is your home street address? Client Address Client City. Client State Client Zip
Occupancy
Where would you like to live?
What location are you applying for? Dropdown
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? Radio buttons
Has recurring substance use resulted in a failure to fulfill major roles at home, work, or school? Radio buttons
Has continued substance use caused social or interpoersonal problems? Radio buttons
Have your important social, occupational, or recreational activities been given up or reduced because of substance use? Radio buttons
Have you been in situations in which substance abuse has put you in physical danger? Radio buttons
Has substance use continued despite having knowledge of persistent physical and psychological problems that may have been likely caused by substance use? Radio buttons
Have you increased the amount of substance use to achieve intoxication or the desired effect and experience diminished effect with continued use of the same amount? Radio buttons
Contacts
Please give us a few people we can contact in an emergency
Contact
Insurance
In the event you need medical or dental care, please provide us with your insurance information.
Do you have insurance? Radio buttons
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 of choice? Client substances of choice
Have you been clinically diagnosed with anything? Client diagnosis
Do you have any health problems? 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 Medical tests? Medical Tests
Are you currently in withdrawal? Radio buttons
Do you have any issues with mobility? Radio buttons
Medications
List the medications you are currently prescribed.
Medication
Treatment Centers
Tell us about any treatment centers you've been previously admitted into.
TreatmentCenterHistory
Suicide Screening
What are your suicidal tendencies?
Do you have suicidal tendencies? Radio buttons
Do you have non-specific suicidal thoughts? Radio buttons
Active suicidal ideation? Radio buttons
Have you had any suicide attempts in the last six months? Radio buttons
Client Referral Source
Where did you hear about us?
How did you hear about us? Text field
What agency referred you to us? Text field
Please provide a name of the person who referred you. Text field
Sober Living History
Tell us about any sober living you have previously been admitted into.
SoberLivingHistory
Employment
Tell us about your employment status
EmploymentHistory
Living Arrangement
Tell us about your living arrangement prior to moving into this facility.
LivingArrangementHistory
Criminal Background
Tell us about your criminal history
Criminal History
Have you ever been convicted of a violent crime? Radio buttons
Have you ever been convicted of a sexual crime? Radio buttons
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.
Date Date
Applicant Signature:
Signature
The Next Step: Here is Matt's phone number - 435-429-1269 - Please call him.