Welcome to the Freshwater Recovery House application wizard.
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Personal
Tell us about yourself
First Name
Client first name
Middle Name? No middle name? Move on to the next question.
Client middle name
Last Name?
Client last name
When is your birthdate (MM/DD/YY)?
Client birthdate
What is your marital status?
Client marital status
If you are divorced or separated was addiction a factor?
Checkboxes
Do you have children?
Checkboxes
If you have children what are their ages? Text field
Do you have custody and/or visitation with your children?
Text field
Has your custody and/or visitation with your children ever been revoked due to your addiction?
Checkboxes
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?
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.
Emergency Contact Contact
Emergency Contact Contact
Medical History
Tell us about your medical history.
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Do you have any health problems? Add multiple by clicking in the box and selecting different options
Client health problems
Do you have any allergies?
Client allergies
Do you have any clinical diagnoses? Add multiple by clicking the box and selecting different options
Client diagnosis
Do you have a civil commitment in the state of Minnesota?
Checkboxes
Have you ever planned or attempted suicide?
Checkboxes
Are you under a physician's care?
Checkboxes
Doctors name and phone:
Text field
Are you under the care of a:
Checkboxes
List the name and phone number of each specialist:
Text field
Text field
Text field
List your current medications:
Medication
How long have you been taking your medications?
Paragraph
Have you suffered any of the following episodes in the last 12 months?
Checkboxes
Are you currently receiving any assistance from any county agencies?
Checkboxes
Chemical Dependency History
Tell us about your chemical dependency history.
How old were you when you first started using drugs/alcohol?
Text field
Name all the drugs you have ever used.
Text field
What drugs (including prescribed medications) have you used in the last 12 months?
Paragraph
Was there drug/alcohol abuse in your family while you were growing up? If so what substances were abused?
Text field
Do you still have close friends who are using drugs/alcohol?
Checkboxes
Do you have family members who are using drugs/alcohol?
Checkboxes
What negative effect has your addiction had on your life?
Paragraph
What is your sobriety date?
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
Can you pass a drug test today?
Checkboxes
What kind of meetings do you attend? Add multiple by clicking in the box and selecting different options
Client kinds of meetings attended
Have you ever replapsed? How many times?
Text field
Legal History
List all past, current and pending legal issues.
Have you ever been arrested or incarcerated for drug use, possession, or intent to manufacture or sell? If so, what year and what were you accused of?
Text field
Do you have any convictions?
Checkboxes
List the type and date of each conviction
Paragraph
List any pending charges/legal issues
Paragraph
Do you have a parole/probation agent?
Checkboxes
Name Text field
Phone Text field
Treatment Centers
Tell us about any treatment centers you've previously been admitted into.
TreatmentCenterHistory
Client Referral Source
Who referred you to us?
Client Referred By
Other:
Text field
Name and Email of the referring person:
Text field
Religion/Spirituality
The Freshwater Recovery House is a Christ Centered long term recovery house, and we name God as our higher power. Please let us know what (if any) experience you have with spirituality. This helps us to understand you better. We do not require or force our beliefs, regardless of your answers. Please answer honestly.
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Do you believe in God?Checkboxes
Have you ever been baptized?Checkboxes
If so where and when? Text field
Have you ever attended church regularly?Checkboxes
If so, where and when? Text field
Do you believe God cares about you?Checkboxes
Financial Information
Tell us a little about your current financial situation
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Tell us about your current employment status. EmploymentHistory
Are you capable of paying rent? Dropdown
How will rent be paid? Dropdown
Are you receiving any income or benefits from any other source other than employment? (examples: social security, inheritance, disability, commission, interest, investments, annuities)
Dropdown
Source and the amount received monthly:
Paragraph
Living Arrangement
Tell us about your current living arrangements
LivingArrangementHistory
Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge.
I understand that false or misleading information in my application may result in immediate discharge
Signature
Signature
Date Date