Application Screen Prospective Client

PRE-ADMISSION APPLICATION

PROSPECTIVE RESIDENT 

SOBER LIVING OF WASHINGTON

 ******** PLEASE NOTE*************

THIS APPLICATION MUST BE FILLED OUT ENTIRELY! If this application is not filled out, and very little detail is included in the responses you provided, this will require another submission or a denial of application. PLEASE read the questions carefully, BE HONEST, and fill out all information to the best of your ability. We want to be sure that we can help you and you are set up for success!!!

 

THIS APPLICATION WILL BE FORWARDED TO OUR MANAGEMENT AND HOUSE MANAGER OF THE HOUSE APPLIED FOR. YOU WILL BE ADVISED OF YOUR APPROVAL OR DENIAL AS SOON AS POSSIBLE. APPROVAL TO OUR HOMES IS NOT GUARANTEED BY FILLING THIS APPLICATION OUT, WE ACCEPT GUESTS ON AN INDIVIDUAL BASIS AND WHETHER OR NOT THE HOUSE WILL SUPPORT YOUR RECOVERY BASED ON WHO RESIDES IN OUR RECOVERY HOMES AT THE TIME OF SUBMISSION. OUR MAIN APPROVAL CRITERIA IS THAT YOU ARE:


·      Medically Stable (not in detox, not in active medical emergency)
·      Mental Health Stable (not in active psychosis, stable on medication, etc.)
·      Ability to pass a UA/ Breathalyzer upon time of entry (THC is subject to discretion due to length of time detectable, usually given 30- 45 days to test negative) 
·      No sexual offenses ever convicted/ Major violent crimes ever convicted.

 

Today's Date:Date              

HOW DID YOU HEAR ABOUT Sober Living of Washington? 

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HAVE YOU READ THROUGH OUR CONTRACT? IF NO, STOP- Go to our website and READ THROUGH THE CONTRACT. www.soberlivingofwashington.com - click on the "get started" tab, there are two links, one for the contract, and one for the application. WE DO NOT NEED A FILLED OUT CONTRACT sent to us, this is just for your information to be sure our structure fits with your needs. 

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DEMOGRAPHIC:  

LEGAL FIRST AND LAST Name: Client first nameClient last name

Nickname, if applicable: Client nickname

Your contact Phone #: Client phone

your Email: Client email

Marital Status?Client marital status

Are you a veteran? Client veteran status


Are you on DOC supervision? Text field

DOC#: Text field

Date of Birth: Client birthdate

Identified Gender: Client gender

Were you born with the genitalia you identify with? Text field

Do you have health insurance? (This is not necessary for our program, just for records) Text field

Type of insurance: Text field

City where you lived last? Client CityClient State


 
SUBSTANCE USE HISTORY:

Identified Substance of Choice (add all that apply): Client substances of choice
Years struggling with addiction (approximate): Text field
Were you an IV user (use needles?): Text field

What is your longest amount of time sober? Text field

What is your CURRENT Sobreity Date? Date of Last Use of ANY substances? Date


Will you test positive on a UA screen upon admission? If yes, what for? If this is not accurate, your agreement to stay with us may be terminated when you arrive.


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LIVING/ TREATMENT HISTORY


Have you been in a Sober Living or Oxford Before? Text field

Have you been kicked out of sober living before? If yes, PLEASE EXPLAIN WHY:
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Have you been in a rehab/treatment program before? Text field

How many times have you been in treatment total? 2 times? 3 times? Text field

What is the name of the last program you attended? Text field 


Did you complete the treatment program? Or Graduate the treatment program? Text field

If no, why did you not complete? : 

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OTHER ADDICTIONS


Do you have Gambling addiction/ Problem Gambling? Text field

If Yes, Describe:

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Have you been diagnosed with an Eating Disorder/ Disordered Eating Habits? Text field

If Yes, Describe:

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LEGAL CHARGES
Have you ever been convicted of a sex crime? Text field

If yes, describe:

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Have you ever been convicted of an arson related crime? Text field

If yes, describe:

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Have you ever been convicted of a violent crime? Text field

If yes, describe:

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Would you be considered a member of a Gang or other criminal organization?Text field

If yes, describe (when was this, are you still affiliated?) :

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Do you have any gang identified tattoos? Where are they located (arms, chest, etc?) Text field


If yes, describe:

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Please list ANY FELONY Convictions as an adult with explanation: 

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Any Charge(s) that are Pending currently? What was the charge?  Text field


PO or LAWYER CONTACT: Text field
 
MEDICAL ISSUES


Questions ahead are for PHYSICAL HEALTH, NOT MENTAL HEALTH- Any hospitalizations or surgeries for PHYSICAL ISSUES in the last year?

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If yes, please describe:

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Are there any ongoing issues from this surgery? Or are you healed completely?

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Do you have any major health conditions?
Chronic PainCheckboxes

Heart ConditionCheckboxes

DiabetesCheckboxes

Lung Problems Checkboxes


Liver ProblemsCheckboxes  

Stairs 10x Daily OK without assistance?Text field

SeizuresCheckboxes

History of communicable diseases? Checkboxes


Explanation of any of the above checked as yes, or please list any physical health conditions not listed that we should know about in case of emergency: 

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ALLERGIES
Any Medication/Food/Other Allergies (bee stings, etc.) (DO YOU HAVE AN EPI PEN?): 

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MEDICATIONS

We do not allow any controlled substance medications other than MAT prescriptions (suboxone, methadone, naltrexone, vivitrol, etc.)

For the safety of our homes, we do not allow Controlled Substances in our homes such as opiates for pain- benzodiazepines for anxiety, stimulants for ADHD, etc.)
Medications examples we would not allow:
Opioids: Drugs like oxycodone (OxyContin), hydrocodone (Vicodin), morphine, and codeine.
Benzodiazepines: Medications such as alprazolam (Xanax), diazepam (Valium), lorazepam (Ativan), and clonazepam (Klonopin) or Temazepam (Restoril)

Stimulants: Drugs like methylphenidate (Ritalin), amphetamine salts (Adderall), and dextroamphetamine (Dexedrine).
Barbiturates: Substances like Phenobarbital and Secobarbital
Sleep Medications: Sedative-hypnotics such as zolpidem (Ambien) and eszopiclone (Lunesta),

Medication(s) Prescribed/ Prescribed Dose(s)/ Prescribed for- PLEASE FILL OUT THE REQUIRED INFORMATION FOR THESE MEDICATIONS- ALL DOSE INFO, WHAT IS THE PRESCRIPTION FOR? (E.G., TRAZADONE- 50mg per day- I take this for sleep issues)

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Any notes or information for medications we should know about?
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Prescribing Physician, where do they work? If you dont know the name of your doctor that is okay, please just give us the place where you go to see your doctor (eg. Dr. Billy at Vancouver Clinic) 

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Are you in need of a doctor to continue your prescriptions? Any other concerns for doctor related items?

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MENTAL HEALTH:


Have you ever been given a formal Mental Health Diagnosis? Text field

Tell us about the diagnosis that you have been given (example: I have been diagnosed with Anxiety and depression, PTSD, Schizophrenia):

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Tell us any information on mental health that would be helpful for us to know: (example: I was diagnosed a few years ago, the PTSD is something i am struggling with lately, etc...)

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Are you able to take your medication without assistance? Are you stable on medication currently? Please add any additional information that would be good for our staff to know about your mental health:

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In your words, are there any symptoms or triggers that we should be aware of in regards to mental health? Anything that was not diagnosed that you think you may be struggling with? 

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Have you ever experienced Auditory or visual hallucinations not under the influence? If yes, we need more information- Are they auditory? Are they visual? What does it sound/ look like? When does this happen most of the time?  Are you on medication for this? Is it helping? PLEASE Provide as much info as you can. 
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Have you ever been hospitalized for mental health issues like psychosis or psychotic issues? In other words, have you been hospitalized in a psychiatric facility? When was this? Tell us everything you are comfortable telling us about this. 
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Have you ever had a suicide attempt that required hospitalization? If yes, how many times has this happened? When was your last attempt? Was a weapon used? How did you get to the hospital? 

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Any history of Self Harm? (Cutting, Burning Yourself, Etc.) If yes, When was the last time this happened? Do you have open wounds currently? Tell us anything you are comfortable sharing:


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GENERAL QUESTIONS:
Why are you choosing to come to Sober Living of Washington at this time?:

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What do you feel like have been your Barriers to Recovery? How can we support you to stay sober while in our program?

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Is there anything else we should know about you? (kids in the area, spouse, work that is set up, IOP or anything else) 

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CONFIRMATION OF CORE TENANTS OF HOW WE OPERATE:


We are a recovery home, therefore we do mandate participation in a Recovery program (AA, NA, Celebrate Recovery, Wellbriety, Church, Dharma Recovery, SMART Recovery, WE DONT CARE WHAT TYPE OF PROGRAM YOU WORK, BUT YOU MUST BE INVOLVED IN SOMETHING FOR YOUR RECOVERY, etc.) of your choice and we require attendance of a minimum of 5 meetings per week. IOP 3x a week would count towards those 5, but we would ask for 3 IOP, and 3 meetings after you get settled. What type of recovery meetings have you attended in the past? Will you be able to complete at least 5 meetings per week?

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Are you willing to get a sponsor/ recovery mentor within 2 weeks of entry to the recovery home, even if it is temporary?

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We have shared rooms at all of our properties, usually 2 people per room but larger rooms have 3 people per room. We DO NOT have bunk beds.  We try to keep the third bed open and not to fill it unless necessary for a person that really needs our structure, but you will most likely share a space with one other person. We do not offer single rooms. Any issues with this or concerns?

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Are you planning to participate in a suboxone, methadone, Vivitrol, or any other MAT program? THIS DOES NOT DISQUALIFY YOU, WE JUST NEED TO KNOW. Describe:

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During your stay- It is your responsibility is to manage your medications and we are not responsible to handle or distribute your medications. ANY medications you have must be stored appropriately, and we must be made aware of any changes to your medication BEFORE you fill your new prescriptions to eliminate concerns of false positives. Sharing medication as well as taking more medication than you are prescribed would be grounds for termination of your stay with us. We do not allow controlled substance medications for respect of other guests in the recovery home. 

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If there is a positive UA/ Breathalyzer test you will have 1 hour to collect your belongings and leave the property, we have zero tolerance for substance use on or off the premises. We test for Kratom and other "head shop" substances, these are not allowed. Anything that comes up on a UA is not allowed in our homes, including CBD products or "near-beer products" for respect of others in the home. It is highly suggested you do not consume anything that could potentially cause a false-positive. Our UAs are very sensitive, and this is the best warning we can give you not to ingest anything that could cause issues. Please do a google search if there is a concern of false positive before you ingest something. Poppyseed muffins, tylenol PM, alcohol based mouthwash, etc. will test you positive!! UA’s are done under visual supervision in our recovery homes at least once per week, sometimes twice per week. Any issues or concerns? 

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For the first two weeks upon entry, you will be in a “blackout” period. We do not take away electronic devices, but we do mandate that if you leave the property- it is communicated with management and approved prior to leaving. Certain activities will require another guest goes with you. Medical appointments, Job Interviews, and some other appointments do not require companionship but do require communication and approval with the house manager. This is to build trust within the community. Our "Golden Rule" for the first two weeks is DO NOT LEAVE WITHOUT PERMISSION FROM THE MANAGER or your stay with us will be terminated. Any concerns? Please be sure if approved that you have a schedule for the house manager for upcoming appointments. 

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Fighting, yelling, or any forms of physical intimidation is not allowed, you will be given a maximum of 2 warnings on behavior before he will be asked to leave the property if it persists. Physical violence is grounds for immediate termination. We have a VERY LOW tolerance for violent behavior or getting aggresive with another guest. We do not allow weapons of any type in the recovery homes.

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What items will you need when you arrive at the home? Food card, clothing, Toiletries, etc.? We do not provide large amounts of storage- it is suggested to bring 1-2 weeks’ worth of clothing. You will be provided with half of a closet, a 3-drawer dresser and space under the bed. We do not allow any furniture of any type to be brought into our homes, but we do encourage to bring your own blankets and pillows if you have them. What would you be brining with you? Any concerns?

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PLEASE NOTE: WE DO NOT ALLOW VISITORS IN OUR HOMES AT ANY TIME EVER- Other than Corrections personnel, community workers, funding agencies, or state agencies. INSURANCE DOES NOT ALLOW US TO PROVIDE HOUSING FOR CHILDREN. WE DO NOT ALLOW OVERNIGHT STAYS WITH CHILDREN OR SPOUSES, NOBODY OTHER THAN GUESTS ARE ALLOWED ON PROPERTY. PLEASE ACKNOWLEDGE:

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Financial Situation- How are you paying for fees? Are you getting assistance from an outside organization? If so, for how long? We will need confirmation of payment agreement for any outisde organizations assisting you with funding. Our Total cost of move in is $1000, $750 sobriety fees per month plus $250 administrative fee.

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When is your projected Move-In Date? When will you arrive? Date
 

WHICH HOUSE ARE YOU WANTING TO MOVE IN TO? ROSEMERE OR CASCADE PARK (MEN'S ONLY) SUNNYSIDE HOUSE (WOMEN'S ONLY) 

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Contact Information for counselors in treatment? Patient ID if in treatment/ PO Contact?

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Client Signature Signature