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