Thank you for your interest in Racing for Recovery. We offer a balanced holistic lifestyle of recovery to all persons affected by addiction. We understand the devastation drugs and alcohol have on self, family and communityand are proud of you to taking ACTION to improve your life.
Racing for Recovery offers an opportunity for those who are ready for an exciting, educational.rewarding and beneficial concept to utilize a program which focuses on healing from emotionaltrauma that lead to a choice to use drugs and alcohol.
Client referral source
Client referred by
Have you received services from us in the past?
Desired Date to Start Services: Date
What types of services would you like to recieve from us? (ex: counseling, IOPs, support groups etc..)
General Contact Info:
First Name: Client first name
Last Name: Client last name
Address: Client Address
City: Client City
State: Client State
Zip: Client Zip
County: Text field
Email: Client email
Phone Number: Client phone
Birthdate: Client birthdate
Gender: Client gender
Marital Status: Client marital status
Do you have a photo ID?: Radio buttons
Do you have a current unrestricted driver’s license? Radio buttons
Are you currently employed? Radio buttons
Are you an active person? If yes, how? (specific as possible) Text field
Do you have Health insurance? Radio buttons
What kind of Health insurance do you have?
Insurance Name: Radio buttons
*If your insurance company is not listed please fill in with your carrier: Text field
Insurance Policy Number: Text field
Insurance Group Number: Text field
Insurance Plan: Text field
*If you do not have the card on you and do not know the information above but know you have insurance, we will gladly retreive that information for you with your full Social Security Number: Text field
Substances of Choice: Client substances of choice
Sobriety Date: Recovery history 1 sobriety date
Are You Currently in Treatment? Radio buttons
Most Recent Treatment Center Name: Treatment center 1 name
Who is your Case Manager/ Social Worker? *insert first name, last name, contact information: Text field
Treatment Admit Date? Treatment center 1 started
Treatment Discharge Date? Treatment center 1 ended
Reason for Discharge: Radio buttons
Are you fully Detoxed? Radio buttons
Where did you stay last night:Radio buttons
If in treatment or jail, do you have a safe sober place to stay when you leave? Radio buttons
Are you on any of the following MAT substances? Suboxone (other than detox), Methadone, Bunavil, Sublocade, Zubsolv, Vivitrol, etc. Radio buttons
*If you answered yes to being on a MAT substance please list what you are on. Text field
Are you a registered sex offender? Radio buttons
Do you have any outstanding warrants? Radio buttons
Are you on probation? Radio buttons
If yes, what court(s)? Text field
Name of Probation Officer(s) Text field
Do you have any felony convictions? Radio buttons
If yes, what? Text field
Do you have any pending sentencing or possible jail time upcoming? Radio buttons
If yes, what is your court date? Date
Why, specifically, do you want to come to Racing for Recovery?
Once your form is submitted, we will contact you for scheduling.
By continuing, you agree that your electronic signature is the legally binding equivalent to yourhandwritten signature. Whenever you execute an electronic signature, it has the same validity andmeaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning ofyour electronic signature or claim that your electronic signature is not legally binding.
I attest that the above information is correct and subject to further background review.