The Better Path Foundation, Inc.
www.thebetterpath.org
Candidate Participant Short Form Application
Welcome to The Better Path Foundation, and thank you in advance for taking time out of your day to complete this Candidate Participant Short Form Application.
This Application will help The Better Path Foundation begin to determine your eligibility toward your becoming a participant of one of The Better Path Foundation recovery houses and entering the TBPF program.
Please note that once you submit this Application, we will reach out to you, and you will be asked for additional information and documentation; as The Better Path Foundation needs your help to better understand you and your situation.
In the event you do not have all the necessary information available while you are filling out the Application, or cannot complete the Application in one sitting, there will be opportunities to save the information you provide in the Application along the way by clicking the "Save for later" button located at the bottom of each page. You may reaccess the Application you started; as long as you save what you have entered by clicking the "Save for later" button as mentioned. Once you click the "Save for later" button, a link will be provided to you so you may go back to the same Application, and continue toward completion of your Application. It is best to copy and paste the link provided to an email or Word document when you click "Save for later;" save the link somewhere you will remember so you have the link available for another time to return to the Application when you are ready to continue toward completion of it.
Please note, that after you click the "Save for later" button while filling out the initial Application, and when you use the link provided to return to the Application at a later time, the Application itself will be appear on one single continuous page versus the initial Application presented on multiple pages. If you need to "Save for later" again, this "Save for later" button will be located all the way to the bottom of the Application. The same identical link will be provided to return to the Application each time you click the "Save for later" button.
Once the Application is complete, at the very end of the Application, there will be a button marked "Submit form" for you to click. Once you click the "Submit form" button, The Better Path Foundation will receive your Application, and you will no longer be able to access or reaccess the Application.
If you have not heard back from someone from The Better Path Foundation within a few days after you submit your Application, please do not submit another Application. You may email us at help@thebetterpath.org, and someone will get back with you as soon as possible to help you.
Thank you for taking the time to complete your Candidate Participant Short Form Application, and we look forward to receiving your completed Application from you.
Sincerely,
Your friends at...
The Better Path Foundation, Inc.
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Candidate Participant Short Form Application
This Candidate Participant Short Form Application (the “Application”) is presented by The Better Path Foundation, Inc., a 501(c)(3), Wisconsin nonprofit corporation, its successors and/or assigns, as their interests may appear (known hereinafter as, “TBPF,” or “our”). The person whose name appears under Applicant's Full Legal Name herein below shall be known herein as the “Applicant,” “I,” “me,” ”my,” “you,” “your,” and “their.”
The Applicant affirms that the information contained in this Application has been fully read by the Applicant or read to the Applicant, and the Applicant fully understands all information, statements and questions, and requests for information contained in this Application. The Applicant warrants and represents that the Applicant is of sound mind at the time the Applicant is completing this Application; is not under the influence of any substances which would impair their understanding of the statements and questions, and requests for information for the Applicant to provide factual and accurate answers, and shall complete and provide answers to the statements and questions, and requests for information truthfully, honestly, and to the best of their knowledge.
By continuing into this Application, you acknowledge, understand, and agree with the above in total.
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I. Personal and Demographic Information
Applicant’s Full Legal Name:
(First) Client first name (Last) Client last name
(Middle) Client middle name Generation, if any (i.e. Jr. or Sr., or II, III, IV) Text field
If you have been known by any alternate names or nicknames, please write in all such names below:
Client nickname
Date of Birth: Client birthdate Social Security Number: SSN
Mobile/Cell Phone: Client phone Email Address: Client email
Instructions:
If the statements or questions below require a Yes or No answer, select either YES or NO. Otherwise, select and/or fill in the appropriate and correct answers to each statement or question, or request for information as provided herein below.
1. I, the Applicant, consent to be contacted by TBPF via SMS, email, phone, and in person using the information provided in this Application for the purposes of reviewing my Application for consideration by TBPF for me to become a participant of a TBPF recovery house and TBPF recovery program.
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2. I, the Applicant, agree and consent to a background check; which may be obtained at any time by TBPF; whether now or in the future, in TBPF’s sole discretion. Please note, TBPF does not accept anyone with a sexual crime, violent crime while sober, or crime of arson.
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3. Have you ever been convicted of a sexual crime, violent crime while sober, or crime of arson?
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4. What is your marital status?
Client marital status
5. What is your gender identity?
Client gender
6. What is your race/ethnicity?
Client race
Client ethnicity
7. Are you a United States veteran?
Client veteran status
8. Are you receiving Social Security Income also known as SSI?
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9. Are you receiving Social Security Disability Income also known as SSDI?
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10. Are you currently employed?
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11. Are you currently enrolled in school?
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12. What is the highest level of education you have completed?
Checkboxes
13. Do you have any professional licenses?
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14. Who is completing the Application? (Select all that apply)
Checkboxes
15. Are you fleeing a domestic violence situation?
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16. Are you in the process of family reunification?
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17. Do you have any children?
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II. TBPF Program Recovery House Details
18. All of our rooms at the TBPF recovery houses are shared rooms; for accountability reasons. Do you have any concerns about sharing a room?
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19. Are you able to go up and down stairs? (All of our recovery homes are at least two-story homes)?
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20. Can you perform and are you willing to do household chores, i.e. wash dishes, vacuum, sweep floors, mow lawn, landscape, etc.?
Radio buttons
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III. Current Living Situation
TBPF understands that everyone has a unique journey. In order for TBPF to better understand your transition to the TBPF recovery house and program, it is helpful to understand your current living situation.
21. What best describes your current living situation? (You may select more than one)
Checkboxes
22. If you have a physical location (such as an apartment, house, or trailer) as your current living situation associated with question 21. above, please provide your physical address:
Address: Text field
City: Text field State: Text field Zip: Text field
23. If you have no permanent place to live and you are currently experiencing homelessness, and you have a mailing address you use to receive mail, i.e. a PO Box, a friend’s or family member’s address, etc., please provide your mailing address below:
Address: Text field
City: Text field State: Text field Zip: Text field
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IV. Emergency Contact Information and
Release of Information Contact
Include at least one Emergency Contact. If you do not have someone to put down as your Emergency Contact, consider including your sponsor, probation officer, parole officer, and/or case manager.
24. Who is your Emergency Contact? (This is who will be contacted in the event of an emergency)
Contact
25. What is the Emergency Contact’s relationship to you?
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26. Do you have any personal references to list below?
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27. If you answered Yes to question 26. above, please provide your personal references below:
Contact
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V. Substances Used
28. When you previously used substances, what was/were your substance(s) of choice?
(Please select all that apply - click inside of the box to make additional selections)
Client substances of choice
29. Do you vape? (Vaping is not permitted while a participant is in our recovery program due to the possible use of THC or CBD cartridges)
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30. Do you have a prescription for medical marijuana?
(Marijuana use is strictly prohibited/not permitted while a participant is in our recovery program, for any reason, whatsoever; even with a prescription)
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31. Do you use THC or CBD products? (THC and CBD use is strictly prohibited/not permitted while a participant is in our recovery program, for any reason, whatsoever)
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32. Are you using any medication assisted treatment (MAT), i.e. Suboxone, Methadone, Vivitrol, etc.?
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33. If you answered Yes to question 32. above, please provide the name of the medical facility provider you go to where medication assisted treatment (MAT) is provided; along with the phone number and what medication this facility/provider provides to you.
a. Name of facility/provider: Text field
Phone No. of facility/provider: Text field
I am prescribed the following MAT: Text field
b. Name of facility/provider: Text field
Phone No. of facility/provider: Text field
I am prescribed the following MAT: Text field
c. Name of facility/provider: Text field
Phone No. of facility/provider: Text field
I am prescribed the following MAT: Text field
d. Name of facility/provider: Text field
Phone No. of facility/provider: Text field
I am prescribed the following MAT: Text field
e. Name of facility/provider: Text field
Phone No. of facility/provider: Text field
I am prescribed the following MAT: Text field
f. Name of facility/provider: Text field
Phone No. of facility/provider: Text field
I am prescribed the following MAT: Text field
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VI. Health
34. Do you have a Primary Healthcare Provider?
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35. Do you have any food allergies?
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36. Do you have seasonal allergies?
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37. If you answered Yes to question 36. above, do you take medication; prescription or over-the-counter medication to treat your allergy(ies)?
(Medication containing Sudafed is not permitted while you are a participant in our recovery program)
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38. Do you have any of the following clinical diagnoses?
(Please select all that apply - click inside of the box to make additional selections)
Client diagnosis
Also, have you been diagnosed with any of the following? (select all that apply)
Checkboxes
39. Do you have any health problems?
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40. If you answered Yes to question 39. above, do you have any of the following health problems?
(Select all that apply - click inside of the box to make additional selections)
Client health problems
41. Are you currently taking any over-the-counter (OTC) medications?
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42. Are you currently taking any prescription medications?
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43. If you answered Yes to question 42. above, please identify each prescription medication you are taking, and the Doctor's name and telephone number who prescribes the medication to you (Please be sure to include the Doctor's office telephone number in the "Notes" field below):
Medication
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VII. Recovery and Treatment
44. Are you currently in a treatment facility or treatment program?
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45. If you answered Yes to question 44. above, please provide the treatment facility or program details below.
Name of facility or program: Text field
Staff Contact Name: Text field
Facility or program phone No.: Text field
How long have you been there: Text field
Is this an inpatient or outpatient facility or program? (Select one):
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46. Have you been in detox recently?
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47. If you answered Yes to question 46. above, please provide the most recent detox facility details below:
Name of facility: Text field
Staff Contact Name: Text field
Facility or program phone No.: Text field
When did you enter into detox? (Provide a date if known, or how many days or weeks ago, i.e. 17 days ago, 30 days ago, 5 weeks ago, etc.):
Text field
What were you there to detox from, what substance(s)?: Text field
48. Which type of meeting(s) do you attend? (Select all that apply)
Checkboxes
If you attend any meetings other than what is listed above, please enter the other meetings you attend: Text field
49. What was the first date of your most recent recovery (What is your clean or sober date)?
Text field
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VIII. Assistance
50. Do you have immediate needs such as clothing or toiletries?
Radio buttons
51. Do you need assistance with any self-help, support group and/or networks within the local community, i.e. peer support counselor?
Radio buttons
52. Do you need help to renew or obtain any forms of identification, i.e. driver's license, state identification card, etc.?
Radio buttons
53. Do you need assistance with any food programs?
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54. Do you need assistance with a Metro bus pass?
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55. Do you need assistance with applying for health insurance through Forward Health/Consortium?
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56. Do you need assistance with referrals to other organizations that may provide for some or all of your TBPF recovery house and program expenses?
(Qualifications are required for such programs that may be available)
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57. Do you need assistance with finding a job/work?
Radio buttons
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IX. Legal Matters
58. Do you have a Probation Officer?
Radio buttons
If you answered Yes to question 58., what is your Probation Officer's name and phone number?
Probation Officer's Name: Text field
Probation Officer's phone number: Text field
59. Do you have a Parole Officer?
Radio buttons
If you answered Yes to question 59., what is your Parole Officer's name and phone number?
Parole Officer's Name: Text field
Parole Officer's phone number: Text field
60. Do you have a Pretrial Services Officer?
Radio buttons
If you answered Yes to question 60., what is your Pretrial Services Officer's name and phone number?
Pretrial Services Officer's Name: Text field
Pretrial Services Officer's phone number: Text field
61. Are you currently involved in any legal proceedings or criminal justice issues?
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62. Do you have a requirement to perform Community Service?
Radio buttons
63. Do you have any court ordered treatment requirements?
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64. Do you have any pending sentencing or possible jail time upcoming?
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65. Are you required to register with any authority for any reason?
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66. Are you on or required to register with the National Sex Offender Registry?
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67. Are there any restraining orders against you?
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68. Are there any restraining orders filed by you against anyone?
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69. Have you been charged or convicted of a felony?
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70. Have you been charged or convicted of arson?
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71. Have you ever commited a violent crime while you were sober?
Radio buttons
72. Do you have any legal requirements to adhere to?
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73. If you answered Yes to question 72. above, select all legal requirements that apply:
(Select all that apply):
Checkboxes
If you have a legal requirement for something other than is listed above, enter it here: Text field
74. Are you currently incarcerated?
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75. If you answered Yes to question 74. above, in what facility are you currently located?
(i.e. FCI Oxford, WI…Oakhill Correctional Institution, Oregon, WI, etc.)
Facility name and location: Text field
What is your expected release date? Date
What is your Case Manager’s name? Text field
What is your Case Manager's phone number or the facility's phone number; if available to you? Text field
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IX. Recovery House Info
76. If you are approved to be a participant of the TBPF recovery house and program, by what date would you like to move in:
Date
77. Do you have a personal relationship with anyone who lives in a TBPF recovery house, or with any TBPF staff or volunteers?
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78. Do you acknoweldge, understand, and agree that in the event you are accepted as a TBPF participant, there are TBPF rules that must be followed, and failure to follow the TBPF rules may lead to your being removed from the TBPF recovery house and program?
Radio buttons
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X. Transportation
79. Do you have a valid driver's license?
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80. If you answered Yes to question 79. above, do you have a vehicle you drive? (i.e. may be owned, borrowed, or rented)
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81. If you answered Yes to question 80. above, do you have valid automobile insurance or does the owner of the vehicle you borrow or whom you rent from have valid automobile insurance?
(Any vehicle you drive while you are a TBPF participant must have a valid auto insurance policy of insurance connected to it)
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82. If you answered No to question 79. above, do you have a State issued identification card?
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XI. General
83. How did you hear about TBPF, or who referred you to TBPF? (Write in your answer)
Paragraph
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Applicant Statement of Fact
I, the Applicant, acknowledge and agree that I have read this Application, or I have had this entire Application read to me. I warrant and represent that I fully understand all of the statements and questions, and requests for information in this Application in order to have entered my answers within this Application; providing all my answers and information with accuracy, truthfully, and to the best of my knowledge.
Initials Text field
Further, I affirm I am of sound mind, fully sober, at the time I completed this Application.
Initials Text field
I authorize TBPF to obtain a background report in connection with my submission of this Application; which TBPF shall obtain in its sole discretion, and may be obtained at any time; whether during the review of this Application, while I am being considered by TBPF to be a participant of the TBPF recovery house and program, or anytime thereafter should I be approved as a participant. I have also signed the TBPF Authorization, attached hereto and made a part hereof.
Initials Text field
I further understand, acknowledge, and agree that TBPF shall rely upon the answers and information contained in this Application that I have provided in consideration of approving me to enter one of the TBPF recovery houses and program. In the event I should be approved to become a TBPF participant, and TBPF shall later learn that I entered any false or misleading information onto this Application, this shall be grounds for my immediate termination/exit from the TBPF recovery house and program; at the sole and complete discretion of TBPF.
Initials Text field
I lastly acknowledge, understand, and agree that completing this Application, and submitting this Application to TBPF, in no way guarantees me that I shall be approved to become a TBPF participant. Until such time as TBPF issues me a written approval confirming that I have been approved to become a TBPF participant, I am not a TBPF participant.
Initials Text field
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.
Signed, Sealed, and Delivered as of the date appearing adjacent to my signature herein below.
Applicant:
Signature: Signature Date: Date
Print Name: Text field
If a third party helped you to complete the Application, please fill out the third party information found on the next page,
and then you may submit your Application.
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In the event this Application was completed with the assistance of a third party; other than the Applicant alone, please print the name of the third party who assisted the Applicant in completing this Application; along with providing the third party’s valid phone number and valid email address. By entering the name and contact information of the third party below, Applicant understands, acknowledges, and agrees that TBPF may contact the third party to ask the third party questions concerning this Application, and may require a Release of Information from you in connection with the third party entered herein below.
In the event a third party assisted you with this Application, and in the event the third party information provided below is invalid, this Application in its totality shall be considered invalid and as such this Application shall be void.
Print Name of Third Party: Text field
Phone No. of Third Party: Text field
Email Address of Third Party: Text field
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Thank you...
for taking the time to complete and submit your Application.
Once you click "Submit form" at the bottom of this page;
assuming you completed all required questions and statements, and requests for information properly,
TBPF will receive your Application.
After which, TBPF will be in contact with you.
In the event you do not hear from TBPF as soon as you would like,
please feel free to email TBPF at help@thebetterpath.org
Please do not submit another Application, or the review process may take even longer.
Thank you again for your submission of your Application,
and have a nice day.