Welcome to Recovery Residence Application
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Please fill out the enclosed form and we will have someone be in touch with you as soon as possible to discuss your entrance into one of our Residential Residences.
What is your first name?
Client first name Client middle name Client last name
When is your birthdate? Client birthdate
What is your gender? Radio buttons
What is your marital status? Radio buttons
STATUS
Are you a veteran? Client veteran status
What is you SSN? SSN
Contact Information
How can we reach you?Radio buttons
What is your email address?Client email
At what phone number can we best reach you at?Client phone
Street Address:Client Address
Client:Client City
Client:Client State
Client:Client Zip
Family Members
Contacts
Give us a few people that we can reach out to in case of an emergency.
Contact
Sober Living History
Tell us about any sober livings you've previously been admitted into.
SoberLivingHistory
Living Arrangement
Tell us about your living arrangement prior to moving into this facility"
LivingArrangementHistory
Any Additional Notes
Client notes
Residential Entrance Requirements
Welcome to an affiliated North Alabama Recovery Residences, a NARR Certified Facility, your new home on the path to healing and hope. We're more than a program; we're a family, and we are pleased to have you with us. Together, we're going to work, grow, and take steps toward a brighter, sober future. Now, every family needs a bit of structure to thrive, and that's what this agreement is all about. It's not about laying down the law; it's about setting us all up for success.
DATE Agreement Reviewed: Date
Your Path, Your Commitment:
Following the House Rules: Just like we've chatted about, your commitment to sticking with our house rules and regulations is key. They're here not just to keep order, but to make sure everyone feels safe and supported.
Earnings and Contributions: We know the value of a hard day's work, and we're here to make sure it counts. Here's how it works:
80% Contribution: If this payment falls in arrears, then 80% of your Net Pay will be paid out of your paycheck during until your account is current.
Repayment of Promissory Note: $250 a week will be due each Friday for repayment of your Promissory Note.
Admission Requirements for Transitional Residential Program. Please answer the Following Questions to see if you Qualify for our Program of Recovery.
Diagnosis of Substance Use Disorder:
Applicants must meet the criteria for a substance use disorder as detailed in the current Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association.
The current Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), outlines specific criteria for diagnosing substance use disorders (SUDs). These criteria are based on a spectrum of behaviors and symptoms, indicating problematic patterns of substance use leading to clinically significant impairment or distress. According to the DSM-5, a diagnosis of substance use disorder requires the presence of at least two of the following 11 criteria within a 12-month period: Have you done any of the Following?
1. Substance is often taken in larger amounts or over a longer period than intended. Radio buttons
2. Persistent desire or unsuccessful efforts to cut down or control substance use. Radio buttons
3. A great deal of time is spent in activities necessary to obtain, use, or recover from the substance's effects. Radio buttons
4. Craving, or a strong desire or urge to use the substance. Radio buttons
5. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home. Radio buttons
6. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance. Radio buttons
7. Important social, occupational, or recreational activities are given up or reduced because of substance use. Radio buttons
8. Recurrent substance use in situations in which it is physically hazardous. Radio buttons
9. Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance. Radio buttons
10. Tolerance, as defined by either of the following: a) a need for markedly increased amounts of the substance to achieve intoxication or desired effect, or b) a markedly diminished effect with continued use of the same amount of the substance. Radio buttons
11. Withdrawal, as manifested by either of the following: a) the characteristic withdrawal syndrome for the substance, or b) the substance (or a closely related substance) is taken to relieve or avoid withdrawal symptoms. Radio buttons
DID YOU ANSWER YES TO ATLEAST 2 OF THE ABOVE QUESTIONS? Radio buttons IF "NO" PLEASE STOP AND SPEAK WITH SOMEONE FROM THE RESIDENCY.
You must have Absence of Acute Intoxication and Withdrawal to be admitted, If these exist we can assist you in entering a Detox Center prior to acceptance.
1. Participants must not be experiencing, nor show signs of, alcohol or drug withdrawal symptoms upon admission, to ensure they are stable enough to engage with the recovery process.Biomedical Conditions and Stability:
2. Any existing biomedical conditions should be stable and should not require medical or nursing supervision. Applicants should be capable of self-administering any prescribed medications.
Emotional,Behavioral, or Cognitive Stability:
1. Individuals should not exhibit symptoms that indicate the presence of psychiatric, emotional, behavioral, or cognitive conditions that would require intensive psychiatric care. Such conditions should be stable and managed independently or through concurrent psychiatric services, without posing a risk to self or others.
Readiness to Change:
2. Admission to the program requires an acknowledgment of the substance use disorder or co-occurring disorders. The individual must express and demonstrate a commitment to engaging in recovery-oriented changes.
Potential for Relapse or Continued Use Risk:
1. The individual should have a history that indicates a high risk of relapse with a less structured environment or a need for structured support to maintain recovery-focused engagement during community reintegration.
Recovery Environment Needs:
1. Applicants likely do not have the resources or skills necessary to maintain a recovery lifestyle outside a dedicated, supportive environment provided by a 24-hour residential program.
All clients have been evaluated and agree to the above diagnosis. All clients will be evaluated by a certified Substance Abuse professional and agree to adhere to the recommendations of the physician during their stay. Failure to comply with Physicians recommendations will result in expulsion from the program.
Core Services:
The Transitional Residential Program is committed to offering basic services that are tailored to the needs of our participants. Our goal is to provide an environment that underpins each individual's journey to recovery, ensuring progress towards sustainable well-being.
Should you wish to discuss these requirements in greater detail or need support throughout the admissions process, our team is ready to assist you. Rest assured, we are committed to providing quality service and support as you take this important step toward recovery.
By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.
By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.
Signature