Program Application

Men, Women & Women w/ Children (recovery restoration homes)

BELOVED HOUSING❤

 

 

ATTENDEE APPLICATION 

ALL AREAS MUST BE FILLED OUT 

Date: Date

Referred by: Client Referred By

Name: Client first name Client last name

Date of Birth: Client birthdate

 

Mobile Phone: Client phone

Alternate Phone: Text field

Email Address: Client email

 

 

Emergency Contact: Text field

Emergency Contact Phone #: Text field

Program your interested in :Checkboxes

 

 How many days sober do you have? Text field

 

Type of insurance : Text field

 

Do you have medi-cal ? Checkboxes

 

Do you have IEHP: Checkboxes

 

Are you on Parole/Probation? : Text field

 

  1. Have you previously resided in a Sober Living or transitional Housing? Checkboxes

1A. Have you been to Rehab? Detox/ Residental SUD Treatment, outpatient IOP? Checkboxes if so when and where? Text field

1B. Have you been in hospital in the last 30 days?Checkboxes

 

  1. Describe your addiction, drug of choice and length of time you have struggled with your addiction:

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  1. Briefly describe your understanding of a 12 step Recovery Program?

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  1. Describe any Parole and/or Probations (include dates and description or put n/a):

 

 

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  1. Describe any physical and/or mental health diagnosis:

 

 

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  1. Describe any physical disabilities: 

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  1. List any medications:

Medication

 

  1. Detail any hospitalizations:

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  1. Describe any suicide attempts:

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Print Name: Client first name Client last name

Date:  Date

Signature:

Signature

 

Witnessed by (if someone is assisting you): Text field

Signature

Date:  Date

 

Additional Comments:

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Questionnaire:

 

 

  • Please write a quick paragraph detailing your addiction story and path to recovery.

 


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  • When was the last time you relapsed?  

 

Please describe.

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  • Are you interested in our Christian Faith based program?   Checkboxes

 

  • Do you participate in 12 step meetings (celebrate recovery , NA, AA, CA ?)Text field

 

 

  • What do you think would be the most difficult obstacle in your recovery?

 

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