Next Chance Recovery Homes

"Take Your Next Chance Here"

 

If you are interested in applying for residency, please complete this general intake form to be added to our waitlist.

First name: Client first name

Last name: Client last name

Preferred nickname: Client nickname

Phone number: Client phone

Email address: Client email

Date of Birth: Client birthdate

Home City/State: Client CityClient State

Next Chance consists of five recovery homes, each with different phases of living. The Pond House (Falmouth), The Farm House (Forestdale), The Ham House (Wareham), Next Level House (Falmouth), and The Graduate House (Falmouth). Which facility are you applying for today? 

Client facility

 

What is your current sobriety date?

(Enter an estimated date for your last relapse if this is not your first attempt in recovery)

RecoveryHistory

What is your substance(s) of choice?

Client substances of choice

 

Have you experienced dependency or over use of psychedelic substances such as psilocybin mushrooms, acid, cannabis sativa, ketamine, DMT, Mescaline, peyote, ayahuasca, or 2C-B?

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Have you ever experienced dependency or over use of inhalants, such as computer/electronic duster or paint thinners/sprays?

Checkboxes

 

 

What medications are your currently taking? 

Please list the names of all your medications:

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Do you have any co-occuring conditions? (Please choose all that apply)

Client diagnosis

Do you have a history of self-harm, self-injury, and/or cutting? 

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Have you ever been diagnosed with an eating disorder, or fear you may have one?

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Do you have any health issues/concerns we should be made aware of?

Client health problems

Do you have any allergies we should be made aware of?

Client allergies

Are you curently pregnant? 

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 If there is anything else you feel necessary to share, please do so here:

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Financial Information:

Do you collect either Social Security or Disability income?

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Are you currently on leave from your job and collect FMLA or laid off and recieve unemployment? 

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Do you have family who can help support you financially?

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Are you in need of a financial scholarship in order to secure sober housing today?

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If yes, where have you applied for scholarship funding? 

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If you are active in a treatment program, please provide your case manger's information so we can reach you:

Case manager name:Text field

Case manager phone number: Text field

Case manager email: Text field

Potential Discharge date: Text field

Do you have any children? If yes, please list their names and ages.

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Do you have any involvement with DCF, Probation, or Parole? (Please specifiy)

Probation 

 

Interests

Are you interested in alternative wellness modalities such as yoga, meditation, and/or acupuncture?

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Do you have an interest in caring for animals? 

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Do you have any experience with homesteading, gardening, or raising farm animals? (If yes, Explain)

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Please press submit when you have completed this form. Someone will reach out to you shortly to complete a phone interview.

Phone interviews can also be arranged by text to 774-258-8573 or by email to Lana.atamian@gmail.com