Application for Admission
Name:Client first nameClient middle name Client last name Date:Date
Current Mailing Address: Client Address
Email:Client email Phone Number:Client phone
Age:Text field DOB:Client birthdate
Marital Status: Client marital status
Biological Sex:Client gender
Gender You Identify As: Text field
Preferred Pronouns:Client pronoun
Ethnicity: Client ethnicity
Are you currently in a relationship? Dropdown
Ages of Children? Text field
Do you have regular contact with your children? Dropdown
If no, please explain:Text field
Who do you consider your main support system?Text field
How often do you interact with your support system?Text field
What are your addictions/drug(s) of choice? Client substances of choice
When was the last time you used: Date How long have you used?Text field
List all drugs you used in the last year:Text field
What other drugs have you tried besides your drug(s) of choice?Text field
What is the longest clean time you’ve had in the last 5 years?Text field
Have you ever been to treatment: Dropdown Where:Text field
When:Date
Are you currently in counseling? Dropdown
Counselor Name: Text field
Are you involved in any recovery program or are you attending any meetings or groups to help you stay sober? Dropdown
If yes, what are they?Text field
How often do you attend?Text field
Do you have a sponsor? Dropdown If yes, how often do you meet?Text field
What are your mental health challenges, if any?Paragraph
Do you have any gang affiliations? Dropdown
Are you on any prescription medications? Dropdown
What medications:
Text field
Are you planning to change prescription medications soon? Dropdown
If so, what new medications will you be taking?Text field
Are you able to use stairs to get to your bedroom? Dropdown
Are you able to climb a ladder to a top bunk? Dropdown
If no, why?Text field
If no, can you provide documentation from a doctor that a bottom bunk is a medical necessity? Dropdown
Are you able to work? Dropdown
When is the last time you worked?Date
What type of work do you do?Text field
Do you have any diseases? Dropdown
If yes what?Paragraph
Do you have any physical limitations?Paragraph
Do you need any special accommodation? Dropdown
If yes, please specify Text field
How did you hear about the Lighthouse: Text field
Are you able to pay $850 on move-in day? Dropdown
Can you pay the recurring monthly program fees of $750? Dropdown
What is your current living situation?Text field
Why do you want to come to the Lighthouse?Paragraph
Are you considering any other facilities besides the Lighthouse? Text field
If accepted to Lighthouse, when do you want to move in? Date
If you are accepted to Lighthouse, will you: definitely move in Dropdown OR are you undecided? Dropdown
How long do you see yourself staying in a program like the Lighthouse? Paragraph
Are you able to make a definite commitment to complete Phases 0-4 of the Lighthouse Program? Dropdown
(This takes a minimum of 4-6 months.)
If accepted to Lighthouse, what goals do you want to achieve while in the program ?Paragraph
Please rate yourself in the area of cleanliness/organization (On scale of 1 to 10) Dropdown
(1 being very messy and 10 being OCD neat and clean)
Are you a heavy, medium, or light sleeper? Dropdown Do you snore? Dropdown
Please list all felonies and misdemeanors, including approximate dates: Paragraph
Have you ever been convicted or accused of a Sexual Crime? Dropdown
Violent Crime? Dropdown Arson? Dropdown
Do you have any outstanding warrants? Dropdown
Are you currently out on bond awaiting trial/sentencing? Dropdown
Are you on Pre-Trial? Dropdown
Pre-Trial Case Manager:Text field
Are you on Probation? Dropdown
Parole Dropdown
Non-Res at the Halfway House? Dropdown
Officer or Case Manager’s Name: Text field
Officer’s Number:Text field
Certifications - Please initial each statement below.
Initials Text field
I understand that it is a requirement to have a clean drug test to move into the Lighthouse, and at all times
while Participating in the Lighthouse program.
Initials Text field
I understand that collection of urine specimens will be supervised by Lighthouse staff to ensure the integrity of the
urine.
Initials Text field
I have read and understand the basic expectations of the Lighthouse Program, including the employment, weekly
meeting, chore, and curfew expectations, and agree to fulfill these expectations if accepted to the program.
Initials Text field
I have read and understand Lighthouse’s Medication Policy and agree to abide by it if accepted to the program.
Initials Text field
I understand that Lighthouse regularly tests for specialty drugs including but not limited to: SubOxone, methadone,
kratom, spice, fentanyl, acid, mushrooms, gabapentin, etc.
I certify that all of the information I have provided on this application is true and complete to the best of my knowledge. I understand that if at any time during my participation in the program at the Lighthouse that the information I have provided is found to be inaccurate or incomplete it will be grounds for immediate discharge from the Lighthouse.
Signature:Signature Date:Date
Printed Name:Signature
By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.
Application for Admission
References to Assist in Admission Decision – Please list references who know you and your addiction history. Lighthouse prefers to have at least 1 professional reference and at least 1 personal reference.
Applicant Name: Text fieldText field Date: Date
Applicant DOB: Text field Applicant SS#: SSN
Parole – Specify County Text field
Abundance Foundation
Probation – Specify County Text field
Larimer County Pre-TrialText field
Larimer County Community Corrections:Text field
Homeward Alliance:Text field
Summitstone Health Partners:Text field
Public Defenders’ Office:Text field
Department of Human Services: Text field
Catholic Charities:Text field
Attorney: Text field
Rescue Mission:Text field
Hospital: Text field
Harvest Farm:Text field
Doctor:Text field
Recovery Coach:Text field
Counselor/ Therapist:Text field
Parents:Text field
Siblings:Text field
Children:Text field
Other Contact(s): Text field
Other Contact(s): Text field
Authorization to Release Confidential Information: I, Text fieldText field, authorize the Lighthouse to retrieve from, release to, and exchange information with the above listed people / entities. I understand that the purpose of this release of information is to assist with my admission decision. I understand that this consent is voluntary and will remain in effect for two years from the date signed, unless I revoke this consent in writing prior to that time.
Signature: Signature Date: Date
By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.
Complete this portion only to REVOKE the Authorization to Release Confidential Information Above:
I, Text fieldText field, hereby revoke my authorization for the Lighthouse to retrieve from, release to, and exchange information with the above listed people / entities as of .
Signature: Signature Date: Date