I Am Recovery Application

 

I Am Recovery Logo

I Am Recovery Application

Program Overview:

Stages:

Stage 1 (Estimated 90 Days):
90Recovery Activities (Min 4 per week, covers various pathways like House Meeting, 12 Step, Clinical, Spiritual, etc.)
Recovery Mentor (Sponsor, Coach, Therapist)
Job

Stage 2 (Estimated 90 Days):
45Recovery Activities (Min 4 per week)
Commitment to a Recovery Program (e.g., 12 step, Refuge, Smart, LifeRing, etc.)
Weekly Group Participation in the chosen program
Be of Service to the recovery community or support for women in the community

Recovery Maintenance (Can continue indefinitely):
4 Recovery Activities per week
Maintain the requirements from Stages 1 and 2

Curfew:
10pm for 30 days
11pm for the rest of Stage 1
12am for Stage 2
No curfew during Recovery Maintenance

Overnights:
None for 30 days
1 per week for the rest of Stage 1
2 per week for Stage 2
3 per week during Recovery Maintenance

Guests:
None for the first 30 days
Family allowed during Stage 1
Female Friends during Stage 2
Men during Recovery Maintenance

Testing & Responsibilities:
Random UA’s (urinalysis tests) - 1 or 2 per week randomly during the stay
Nightly Breathalyzer tests (first 30 days)
1 Weekly Assigned chore
1 Weekly Assigned service hour

Fees:
Intake Fee: $220
Monthly Bed Fee: Starts at $950 for shared rooms, varies based on room type
Invoices due monthly on the date of move-in, $5/day for late invoice payments or payment plans
Invoices are non-refundable
30-day notice for move out required

What to Bring:
Food, Transportation, Clothes, Med Box, and Hygiene products

Locations:
Arvada West (64th and Kipling)
Denver (Federal and Alameda)
Englewood (Hampden and Federal)
Littleton (Bowls and Wadsworth)
Littleton West (Sims & Quincy)

After submitting an application, call us at: 720-432-3034

Click next to begin!

General

Tell us about yourself
What is your first name?
Client first name
What is your middle name? No middle name? Move on to the next question.
Client middle name
What is your last name?
Client last name
When is your birthdate?
Client birthdate
What is your race?
Client race
What is your ethnicity?
Client ethnicity
What is your primary language?
Text field
What is your secondary language?
Text field
What is your gender?
Client gender
How do you identify?
Client pronoun
What is your marital status?
Client marital status
Are you a veteran?
Client veteran

Contact Information

How can we reach you?
What is your email address?
Client email
At what phone number can we best reach you at?
Client phone
Street Address:
Client Address
City:
Client City
State:
Client State
Zipcode:
Client Zip

Contacts

Give us a few people that we can reach out to in case of an emergency.
Emergency Contact Name: Contact
Relationship: Text field
Phone Number: Text field
 
Family Member Contact Name: Family Members
Relationship: Text field
Phone Number: Text field
 

Insurance

Enter your insurance provider(s).
Insurance

Medical History

Tell us about your medical history.
When is your last date of use?
Recovery history 1 relapse date
What is your substance(s) of choice? Add multiple by clicking in the box and selecting different options
Client substances of choice
Have you been clinically diagnosed with anything? Add multiple by clicking in the box and selecting different options
Client diagnosis
Do you have any health problems? Add multiple by clicking in the box and selecting different options
Client health problems
What kind of meetings do you attend? Add multiple by clicking in the box and selecting different options
Client kinds of meetings attended
What allergies do you have? No allergies? Move on to the next question.
Client allergies

Have you had any of the following tests?

Medical Tests
 

Do you have any previous Suicide Attempts? Dropdown

If Yes, what is the number of attempts: Text field

When was the last attempt: Date

Have you ever overdoesed? Dropdown

If Yes, how many times: Text field 

When was the last attempt: Date

Do you currently suffer with or have you ever suffered in the past with an eating disorder? Dropdown

If Yes, please give further details: Paragraph

What date did you last actively engage in the eating disorder? Date

Legal History

Tell us about your Legal History.

 

In order to be considered for admission to I Am Recovery, LLC we will first run a background check. Do you agree to this? Dropdown

Are you currently on Probation? Dropdown

If Yes, when was the date of your last arrest: Date 

What charges are pending? Paragraph

Are you currently on Parole? Dropdown

If Yes, what was your release date: Date

What charges were you convicted for? Paragraph

Are you a registered Sex Offender? Dropdown

Do you have any charges of Assault? Dropdown

 

Medications

List the medications you are currently prescribed.
Medication

Treatment Centers

Tell us about any treatment centers you've previously been admitted into.
TreatmentCenterHistory

Client Referral Source

 

What facility (if any) did you transition from into I Am Recovery? If you don't see the name of the facility in the dropdown please type it in: Client Referred By

AND/OR

What person (if any) referred you to I Am Recovery? Text field

Occupancy

What date are you looking to be admitted on?
Date
What is the estimated length of stay?
Client estimated length of stay

Sober Living History

Tell us about any sober livings you've previously been admitted into.
SoberLivingHistory

Employment

Tell us about your employment status.
If you're currently unemployed select "unemployed" under "type"
EmploymentHistory

Living Arrangement

Tell us about your living arrangement prior to moving into this facility
LivingArrangementHistory