We Are One Recovery Housing Application

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We Are One Recovery Housing Application

Case Coordinator Information

If this form is being filled out by a Case Coordinator (someone other than the future client), please let us know how to reach you here: 

Case Coordinator Name: Text field

Case Coordinator email: Text field

Case Coordinator phone: Text field

Case Coordinator relationship to the applicant: Text field

Case Coordinator organization/position/location: Text field

 

General Applicant Information

First name:
Client first name

Middle name:
Client middle name

Last name:
Client last name

Birthdate:
Client birthdate

Pronouns:
Client pronoun

Preferred name: 
Client nickname

Legal Name (if different):
Text field

Race:
Client race

Ethicity:
Client ethnicity

Gender Identity (choose from menu, or write-in your answer): 
Client gender

Sexuality (choose from menu, or write-in your answer):
Dropdown

Marital status: 
Client marital status

Veteran status:
Client veteran status
 

Contact Information

Email:
Client email

Phone:
Client phone

If you are at a facility, please list the contact phone number for that facility:
Text field

(Prior) Street Address:
Address:
Client Address

City: 
Client City

State:
Client State

Zip Code:
Client Zip

 

Emergency Contact

Who can we contact in case of an emergency?
Contact

 

Substance Use History

RecoveryHistory

What is your substance(s) of choice? (add multiple by clicking in the box and selecting different options)

Client substances of choice

Do you have a sponsor?

Client sponsor

 

Medical and Mental Health History

List any health problems: (add multiple by clicking in the box and selecting different options)
Client health problems

Have you been tested for HIV?
Checkboxes

Are you a person living with HIV?
Checkboxes

List any mental health diagnoses: (add multiple by clicking in the box and selecting different options)
Client diagnosis

List any allergies: (please list allergies to medications and food)?
Client allergies

Please list the medications you are currently prescribed:
Medication

 

Do you have a history of trauma?
Checkboxes

 

Do you receive SSI or SSDI benefits?
Checkboxes

Are you currently pregnant?
Checkboxes

Is there anything else we should know about your medical or mental health? 

Client medical notes
 

InsuranceHo
We are unable to accept insurance to bill for our services.
This information assists us in medical emergencies.

Please enter your medical insurance provider(s):
Insurances

  

Treatment Centers

Tell us about any treatment facilities you've previously been admitted into, including rehab and psychitric facilities:
TreatmentCenterHistory
 

Client Referral Source

Who referred you to us?
Dropdown

Specific Referral Information (Facility, staff name(s), etc.)
Text field

Sober Living History

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

Employment

Are you currently employed
Checkboxes

If yes, where/how long?
Text field

 

Criminal History

Criminal History 

Do you have a past history of violence, or any charges for violence?

Checkboxes

If so, please explain

Paragraph

 

Parole or Probation Information

Probation

Probation Officer Contact Information:

Probation Officer Name: Text field

Probation Officer Phone: Text field

Probation Officer Email: Text field

 

Admission Information

What date are you seeking to be admitted at We Are One Recovery?
Date

How long do you plan to stay with us?
Client estimated length of stay

 

Suicidality

Have you ever attempted suicide?

Checkboxes

If yes: When? Please describe?

Paragraph

Have you had suicidal ideations in the past month?

Checkboxes

If yes: When? How Often? How long did it last?

Paragraph

 

Other Questions

Do you have a vehicle? If so what is the make/model?
Text field

Is there anything else you want us to know about you?

Paragraph

 

Applicant Agreement

I voluntarily answered these questions without coercion or under the influence of any mood-altering substances.

Checkboxes

Please click below to review our guidelines to ensure you understand and agree to follow them if admitted:

We Are One Recovery Guidelines


Checkboxes I have read and agree to these guidelines. 

 

Applicant Signature:

Signature      Date: Date