Application

 Just Breathe Recovery Community

Housing Application

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?
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What is your race/ethnicity?
Client race
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

 

Emergency Contacts

Give us a few people that we can reach out to in case of an emergency.
Contact
 
Initials Text field  Initial to accept the following terms. 

I give permission for Just Breathe Recovery Community to contact my emergency contacts for any and all emergencies, or after being consulted, for any general issues deemed as a barrier to my improved mental and physical well-being.

Insurance

Enter your health insurance provider(s).
Insurance

Background and Medical History

Tell us about you and your medical history.
 
Who referred you / told you about Just Breathe Recovery?
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How soon do you need /will you be willing to go to sober living?
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Does the sober living need to TDOC approved?
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Do you currently have any aggravated charges?  Is so, explain
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Are you listed on the Sex Offender Registry?
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When was your last relapse date /time that you used?
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
Are you an IV user?
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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
Do you have any disabilities?
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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
 
 

Medications

List the medications you are currently prescribed.
Medication
 
Just Breathe Recovery follows all state and federal guidelines regarding MAT protocol including methadone, buprenorphine, and naltrexone.  I understand and agree that all medications must be approved by staff. This includes all prescriptions or over the counter medications that may become necessary throughout my stay at Just Breathe Recovery Community.  There are no exceptions to this agreement.
Initials Text field  Initial to accept these terms.

Treatment Centers

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

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

Vehicle Information

Tell us about what you drive.

Year

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Make

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Model

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Color

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Drivers License Number?

Text field

Car Insurance Provider?

Text field

Living Arrangement

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

LivingArrangementHistory

Finances

Initial to accept these terms. 

 

I agree to pay a one-time application fee of $100.  Initials Text field

I agree to pay $250 a week. Initials Text field

I understand that the application fee plus first week fees are to be paid prior to entry.  Initials Text field

I understand that housing fees are due each week on Friday by 5pm.  Initials Text field

I understand and agree that if I fall behind 2 weeks on my housing fees, I will be referred to a more suitable/appropriate residence. Initials Text field

By submitting this document, I agree that all information is accurate and truthful.  Initials Text field