PRE-ADMISSION APPLICATION
PROSPECTIVE RESIDENT
SOBER LIVING OF WASHINGTON
Date:Date
HOW DID YOU HEAR ABOUT SLoW?
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DEMOGRAPHIC:
Name: Client first nameClient last name
Nickname, if applicable: Client nickname
Phone #: Client phone
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
Route of Use (smoke, IV, snort?): Text field
Longest amount of time sober? Text field
How often were you using prior to current sobriety? (Daily, weekly, Binges, etc): Text field
Date of Last Use of ANY substances/ CURRENT Sobriety Date: Date
Will you test positive on a UA screen upon admission? 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 Sober Living Before? Text field
Why did your last sober living program end?
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Have you been in a treatment program before? Text field
How many times have you been in treatment? Text field
Last program attended? Text field
When did you get there? Date
How long were you there for? Or are you there currently?
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Did you complete/ Graduate? Text field
If no, why did you not complete? :
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OTHER ADDICTIONS
Problem Gambling? Text field
If Yes, Describe:
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Eating Disorder/ Disordered Eating Habits? Text field
If Yes, Describe:
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Any other addiction issues we should know about?:
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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:
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Do you have any gang identified tattoos? Text field
If yes, describe:
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Please list all FELONY Convictions as an adult with explanation:
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Any Charge(s) Pending? Text field
Upcoming Court Date(s)? 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 any physical health conditions not listed:
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ALLERGIES
Any Medication/Food/Other Allergies (bee stings, etc.) (DO YOU NEED EPI PEN?):
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MEDICATIONS
(We do not allow any controlled substance medications, 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:
Medication
Any notes or information for medications we should know about?
Client medical notes
Prescribing Physician:
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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
Diagnosis(S): (PLEASE ADD ALL THAT APPLY)
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Are these recent diagnosis? Tell us any information on mental health that would be helpful for us to know.
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Are you able to take your medication without assistance? Are you stable on medication currently? Please add any additional information.
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Diagnosing Doctor: Text field
In your words, are there any symptoms or triggers that we should be aware of in regards to mental health? :
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Have you ever experienced Blackouts not under the influence of substances?
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Have you ever experienced Auditory or visual hallucinations not under the influence?
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Have you ever been hospitalized for mental health issues like psychosis or psychotic issues?
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Have you ever had a suicide attempt that required hospitalization?
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How Many? When was your last attempt? General description of what happened?
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Any history of Self Harm? (Cutting, Burning Yourself, Etc.):
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GENERAL QUESTIONS:
Did someone give you an ultimatum that helped you make the decision to enter sober living? Why are you choosing to come to Sober Living of Washington instead of another program 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 abstinent while in our program?
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Any goals you have that you would like to accomplish in while in a recovery home environment?
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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, 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 some rooms have 3 people per room. We do not have bunk beds or anything like this. 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? 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 I 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. 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?
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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 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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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 WITHIN 24-48 HOURS OF SUBSMISSION. APPROVAL TO OUR HOMES IS NOT GUARANTEED, 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)
· No sexual offenses ever convicted/ Major violent crimes ever convicted.
NOTES FOR STAFF (PLEASE LIST PO OR CONTACT PERSON IF APPLICABLE):
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.
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Projected Move-In Date? Date
House Choice? Client facility
Contact Information/ Patient ID if in treatment/ anything else?
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Client name: Text field
Client Signature Signature