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Standing By the Door Recovery Ministry

-John 10:9

704 S. Veterans Blvd Branson Mo 65616

Email:      intake@

    standingbythedoor.net                                                      

 

******PLEASE NOTE THAT ALL FIELDS NEED TO BE COMPLETED!*********   

                 If it does NOT apply to you please mark as N/A

 

 

DATE: Date  Category: Client categories Phone #: Client phone

Applicant’s full name: Client first nameClient middle nameClient last name

(Print) First, Middle, Last

DOB: Client birthdate SS # SSN

DOC #Date

E-mail: Client email

Current Living Situation: Text field Since: Date

 Do you understand that in order to enter our recovery program that you must ne willing to work the 12 steps?  

Previous Living Situation: City Text field State:Text field

 

Expected move-in date: Date

Estimated dishcharged date: Client discharge date

Level of Education Text field

Marital Status: Client marital status

Spouse/Significant Other's Name Text field

Gender: Client gender 

 

Do you have a Social Security Card? Radio buttons

Do you have your birth certificate? Radio buttons

Do you have a valid driver’s license? Radio buttons

Do you have a non-driver state ID?  Radio buttons

Do you have your own vehicle? Radio buttons

Driver’s License or ID# Text field State: Text field

License Plate # Text field

If yes, what is the name of your car insurance agency? Text field

Policy #: Text field Expiration Date: Text field

Please note that failure to bring a vehicle not fully legalized will result in restriction of driving privileges until the proper documentation is provided.

 

Do you understand that if you are not on legal disability or retirement that you will need to maintain full-time employment to participate in our housing opportunity and if you are on legal disability or retirement you will be required to fulfill 20hrs/wk of community service or volunteer work?

 Do you have children? Radio buttons

 Names/Ages of Children 18 and younger: Family Members

 Do you have visitation with your children? Radio buttons

What days, or how often? Text field

Child Support: $Text field  monthly $ Text field Overdue

 

Legal:

Have you been accused or convicted of a violent crime? YES  or NO

** This includes any Assault, Domestic Violence and/or Child Endangerment charges even if they are misdemeanor charges! If yes, please explain:

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***please note that crimes of this nature does NOT automatically disqualify you from our program, as we review each person’s charges on a case-by-case basis!***

 

Please list any pending charges:

 Paragraph

 

Please list all Felony Convictions:

Paragraph

Are you a registered Sex Offender or will you have to register as an Offender upon your release from prison?  Radio buttons  

 

Do you have a Probation/Parole officer or caseworker? Type PO/Caseworker’s Name in "Notes" below: Probation

Telephone #: Text field AND County: Text field

 

Emergency Contacts:

Contact

 

Medical History:

Are you currently under a doctor’s care? Radio buttons

Name(s) of doctor: Text field

Address: Text field

Phone # Text field

 List any medical issues: Client health problems

What medical issues should we be aware of? Text field

What medications are you currently taking? Medication

 

History of….

Seizures: Radio buttons  If yes, dates: Text field

TB: Radio buttons If yes, dates: Text field

Diabetes: Radio buttons If yes, dates: Text field

Hepatitis: Radio buttons  If yes, dates: Text field

HIV/AIDS: Radio buttons If yes, dates: Text field

Other:(anything you may feel we need to know: Radio buttons If yes,

dates:Text field

 

Mental Health:

Have you ever been diagnosed with a mental health diagnosis? Radio buttons

If so, what are your diagnoses? Client diagnosis

Are you receiving mental health treatment? Radio buttons

If yes,

Who:Text field

Where:Text field

Do you take medication for your diagnosis? Checkboxes

 

If yes, what medications are you currently prescribed?

Medication

When was the last time you met with a mental health specialist? DATE:Date

Do you feel like you need to meet with a mental health specialist? Radio buttons

 

Addiction History:

 

Drugs of choice?  Client substances of choice

Age at first use? Text field

Method of use?Text field

Date of last use? Text field

 

Why is now the time and How serious are you?  Paragraph

What do you hope to get out of our program?Paragraph

 

Spirituality:

Are you aware that SBTD is a Faith Based sober living environment? Radio buttons

Are you aware we teach the 12-steps of Alcoholic’s Anonymous? Radio buttons

Are you willing to work the 12-steps of A.A.? Radio buttons

Have you ever lived in recovery housing before? Radio buttons  If yes,

SoberLivingHistory

 

Are you a Veteran of the United States Armed Forces  Radio buttons

 

As a member in one of our homes, are you willing to comply with all the house rules and expectations? Radio buttons

 

Entry fees are $340.00 should you pay in advance and decide not to come only $140.00 is reimbursable. If you show up and decide not to stay $0 is reimbursable.

Who will be paying your entry fees? Radio buttons

Name of who is paying:Text field

Number:Text field

 

Signature: Signature

Date Signed: Date