Recovery Residence Funding Request

Your information: 

Name: First: Client first name Last: Client last name 

Date of Birth:Client birthdate   

Phone: Client phone 

Email: Client email

SOBER LIVING ARRANGEMENTS:

Where are you currently staying? Text field

How long have you been in a recovery residence?Text field

How much is the Program Fee contribution?Text field

Any infractions at the house? Dropdown 

If Yes Please Explain:

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Have you been asked to leave a recovery residence? Dropdown  

If yes, why?

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RECOVERY:                                                                        

How long have you been clean and sober? Text field 

Drug of choice Please list all. Text field

INCOME/EMPLOYMENT:

Are you working? Dropdown  If So, For How long? Text field
Do you receive disability benefits?Dropdown
Do you volunteer? Dropdown  If So Where?Text field
Do you attend school? Dropdown

   Where? Text field

Program Fee:

Are you currently behind on the Program Fee?Dropdown
How did you pay last month’s Program Fee?  Text field
How will you pay next month’s Program Fee?  Text field

OTHER:

Do you have a Mental Health Diagnosis?Dropdown

Diagnosis:Paragraph                                                                                

Have you been prescribed any Medications for this diagnosis? Dropdown  

Medications: Paragraph

Do you have any health conditions? Dropdown          

 Medications for this condition: Paragraph

Are you on Probation or Parole? Dropdown

Please List the Charges:

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Who is Your Parole/Probation Officer First: Client first name Last: Client last name

Parole/Probation Officer Phone Number Client phone

Parole/Probation Officer Email Client email                                  

Are you a sex offender? Dropdown
 

Please follow the instructions of each prompt and answer each question thoughtfully. 

Paragraph 1: Tell the Diversus Health Network team about yourself. What led you to substance use? Do you have a history of traumatic events? Please explain. 

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Paragraph 2: What is your plan for sober living/recovery residence? How will a recovery residence help you?

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Paragraph 3: Please list 3 goals for your recovery. What steps will you take to complete these goals? How are you working your program (therapy, meetings, groups)? What coping skills do you use?  

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Paragraph 4: What are you doing differently or plan to do differently not to fall back into your addiction? 

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Signature: Signature

Date Form Completed: Date