Recovery Residence Funding Request
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:
Have you been asked to leave a recovery residence? Dropdown
If yes, why?
How long have you been clean and sober? Text field
Drug of choice Please list all. Text field
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
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
Do you have a Mental Health Diagnosis?Dropdown
Have you been prescribed any Medications for this diagnosis? Dropdown
Do you have any health conditions? Dropdown
Medications for this condition: Paragraph
Are you on Probation or Parole? Dropdown
Please List the Charges:
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.
Paragraph 2: What is your plan for sober living/recovery residence? How will a recovery residence help you?
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?
Paragraph 4: What are you doing differently or plan to do differently not to fall back into your addiction?
Date Form Completed: Date