LEGACY ADMISSIONS APPLICATION

 

 

Legacy Home Application 

 

General

What is your first name?
Client first name
What is your last name?
Client last name
What is your SSN?
SSN
When is your birthdate?
Client birthdate
What is your race/ethnicity?
Client race
What is your gender?
Client gender
What is your marital status?
Client marital status
Are you a veteran?
Client veteran

Housing Info

Are you presently homeless or at-risk of homelessness? Checkboxes  Checkboxes


If YES, reason for homelessness:
Paragraph

Please explain your reason for seeking a long-term residential treatment house.

Paragraph

Personal Contact Info

 
What is your email address?
Client email
At what phone number can we best reach you at?
Client phone
Do you have the following:(Write yes or no by each)
License:Text field
ID:Text field
Social Security Card:Text field
Birth Certificate:Text field
 
Street Address:
Client Address
City:
Client City
State:
Client State
Zipcode:
Client Zip

Contacts

Who can we reach out to in case of an emergency.
Contact

Legal History

Legal Issues (Legal Issues Do Not Necessarily Prohibit Residence; Public Record Will Be Checked)

Do you have any upcoming court dates? Text field

If YES, what are the dates and what city? Text field

Do you have any legal convictions? Checkboxes

If YES, what is the charge? Text field

Are you currently on probation?Text field 

Probation

If yes, for what charge? Text field

Name of Probation/ Parole Officer: Text field

Phone number: Number field

Are you a registered sex offender? Checkboxes

Have you ever been convicted of Domestic Violence? Checkboxes

Do you have a Restraining Order filed against you? Checkboxes

Have you ever comitted an act of Arson (intentionally damaging or destroying property through fire or explosion)? Checkboxes

Medical History

Tell us about your medical history.
When was your date of use?
Recovery history 1 relapse date
What is your substance(s) of use? Add multiple by clicking in the box and selecting different options
Client substances of choice
Have you been clinically diagnosed with any disorder? Add multiple by clicking in the box and selecting different options
Client diagnosis
Do you have any health problems? Add multiple by clicking in the box and selecting different options
Client health problems
What allergies do you have? No allergies? Move on to the next question.
Client allergies

 

 

Medications

List the medications you are currently prescribed.
Medication

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

 
 

Employment

Tell us about your employment status for the past 2 years. 
If you're currently unemployed select "unemployed" under "type"
EmploymentHistory

Client Authorization Form (Disclosure of Information Will Be Held in Strict Confidence)
I authorize The Legacy Home of Recovery to conduct a thorough personal investigation including, but not
limited to:

 Credit Reports
 Employment/Income Verification
 Reference Checks
 Current and Previous Landlords
 Law Enforcement Authorities
 Criminal Background Checks
 School Records
 Drug Screen Check
 Health Records
 Family Members
I understand that any cost associated with these investigations will be at the expense of The Legacy Home of
Recovery.
I hereby release these third parties from all liability for any damage whatsoever for providing information to
The Legacy Home of Recovery in connection with this application. I also release The Legacy Home of
Recovery and, its agents, employees and representatives from any liability in connection with their collection
and use of information obtained from third parties during this application process.
I also understand that if I do not provide authorization to this investigation, or refuse to complete the criminal
background check, or drug screen test, the Legacy Home of Recovery Board may not provide approval for
residency. I agree to hold the LHR Board harmless for such refusal. 
 
Date:Date
 
Signature:
Signature