One Step

Housing Application

Click next to begin!

General

Tell us about yourself

What is your first name?

What is your middle name? No middle name? Move on to the next question.

What is your last name?

When is your birthdate?

What is your race/ethnicity?

What is your marital status?

Are you a veteran?

Contact Information

How can we reach you?

What is your email address?

At what phone number can we best reach you at?

Street Address:

City:

State:

Zipcode:

Emergency Contacts

Give us a few people that we can reach out to in case of an emergency.

Contact #1
name:
phone:
email:
type:
Contact typeDon't see the option you're looking for? Click here
notes:

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 #1
Client insurance provider:
Client insurance plan:
Client insurance group ID:
Client insurance policy #:
Client insurance other:

Background and Medical History

Tell us about you and your medical history.

Who referred you / told you about Just Breathe Recovery?

How soon do you need /will you be willing to go to sober living?

Does the sober living need to TDOC approved?

Do you currently have any aggravated charges? Is so, explain

Are you listed on the Sex Offender Registry?

When was your last relapse date /time that you used?

What is your substance(s) of choice? Add multiple by clicking in the box and selecting different options

Substances of choice

Are you an IV user?

Have you been clinically diagnosed with anything? Add multiple by clicking in the box and selecting different options

Diagnosis

Do you have any health problems? Add multiple by clicking in the box and selecting different options

Health Problems

Do you have any disabilities?

What allergies do you have? No allergies? Move on to the next question.

Have you had any of the following tests?

Medical Tests #1
type:
TypeDon't see the option you're looking for? Click here
performed_on:
notes:
result:
ResultDon't see the option you're looking for? Click here

Medications

List the medications you are currently prescribed.

Medication #1
Name:
Dosage:
Quantity:
Category:
Choose category...Don't see the option you're looking for? Click here
Frequency:
Md:
Notes:
Pill count:
Discontinued at:

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.

Initial to accept these terms.

Treatment Centers

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

Treatment Center History #1
name:
address:
city:
state:
zip:
started:
ended:
notes:
type:
Treatment center typeDon't see the option you're looking for? Click here
reason for discharge:
Treatment center reason for dischargeDon't see the option you're looking for? Click here

Sober Living History

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

Sober Living History #1
name:
description:
address:
city:
state:
zip code:
admitted:
discharged:
estimated length of stay:
reason for discharge:
Sober living reason for dischargeDon't see the option you're looking for? Click here

Employment

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

Employment History #1
Employer name:
Employment position:
Employment income:
Employment incomeDon't see the option you're looking for? Click here
Employment started:
Employment ended:
Employment type:
Employment typeDon't see the option you're looking for? Click here
Employment notes:

Vehicle Information

Tell us about what you drive.

Year

Make

Model

Color

Drivers License Number?

Car Insurance Provider?

Living Arrangement

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

Living Arrangement History #1
arrangement:
Living arrangementDon't see the option you're looking for? Click here
started:
ended:
notes:

Finances

Initial to accept these terms.

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

I agree to pay $250 a week.

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

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

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.

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