Date of Application: Date

Personal Information:

First Name: Client first name

Middle Name: Client middle name

Last Name: Client last name

Last Address (not a treatment/recovery program): 

Client Address Client City Client State Client Zip

Date of Birth:Client birthdate

Email Address: Client email

Phone Number: Client phone

Social Security Number: SSN

Marital Status: Client marital status

Are you a Veteran: Client veteran status

Current Living Situation: Text field

LivingArrangementHistory

Person Completing Application Name: Text field

Alternate Contact Phone Number: Text field

Alternate Contact Email Address: Text field

Relationship to Alternate Contact: Text field

Race/Ethnicity:

Client race

Denomination Affiliation: Text field

Level of Education Completed:EducationHistory

Employment History (Must List last 3 jobs): 

EmploymentHistory

Legal History:

Criminal History:Criminal History

Probations: Probation

Are you currently on probation, parole, TASC, Court referral, or Community Corrections?

Checkboxes
If yes, please specify: Paragraph
Supervising Officer/Court Name: Text field

Supervising Officer/Court Phone Number: Text field

Supervising Officer/Court Phone Number:Text field

Do you have any pending legal cases or charges?

 Checkboxes

If yes, please list below:

Charge: Text field

Date: Date

County: Text field

Court Date: Date

 

Charge: Text field

Date: Date

County: Text field

Court Date: Date

Have you been convicted of a felony?

Checkboxes

If yes, what were the charge(s)? Text field

Are you a registered sex offender?

Checkboxes

Do you have any current legal obligations (e.g., fines, community service)? 

Checkboxes

If yes, please describe: Paragraph

Substance Use History:

Client substances of choice

Primary Substance of Use: Text field

Secondary Substance of Use:Text field

Age of First Use (Primary Substance): Text field

Date of Last Use: Date

Have you ever experienced any substance-related health problems (e.g., liver issues, infections, seizures)?

Checkboxes

If yes, please describe:

Client health problems

Mental Health History:

Have you ever been diagnosed with a clinical diagnosis of: (Check all that apply) Checkboxes

Are you currently taking any psychiatric medications? 

Checkboxes

Please list ALL medications you are currently prescribed:

Medication

Have you ever received mental health counseling or therapy? Checkboxes

If yes, when and for what reason? Paragraph

 

Recovery and Treatment History

List all Programs attended in the last 5 years:

TreatmentCenterHistory

 

 

Have you participated in any mutual support groups (e.g., AA, NA, Celebrate Recovery)?

Checkboxes

If yes, which ones and for how long? Paragraph

What are your primary goals for your recovery at Restoration Springs? Paragraph

What are your expectations for your time at Restoration Springs? Paragraph

Social Support and Resources:

Do you have family or friends who are supportive of your recovery? Family Members

Do you have a vehicle?

Checkboxes

Do you have a valid driver’s license?

Checkboxes

 

 

Functional Assessment:

Are you able to independently manage your personal hygiene?

Checkboxes

Are you able to prepare your own meals?

Checkboxes

Can you get along with others in a residential environment?  

Checkboxes

Can you manage your mental and physical health needs without assistance? 

Checkboxes

Do you have any physical limitations or legal reasons that may affect your ability to participate in program activities and gain full-time employment? 

Checkboxes

If yes, please describe: Paragraph

Identification:

Do you have two forms of identification in your possession suitable for obtaining employment (e.g., driver's license, social security card, birth certificate, passport)? 

Checkboxes

If yes, list what you have:

Text field

If not, do you have the resources to obtain them? 

Checkboxes

Survey:

On a scale of 1 to 10 (where 1 is not at all and 10 is extremely), how would you rate your current level of motivation to stay sober?

Dropdown

On a scale of 1 to 10, how would you rate your current level of hope for your future? 

Dropdown

How would you describe your current quality of life? Paragraph

Authorization and Understanding:

- I understand that filling out this application does not guarantee admission to Restoration Springs. 

- I understand that there may be additional background information needed at a later date. - I understand that the Will Bright Foundation may look into the validity and accuracy of all information provided. 

- I understand that failure to provide truthful and accurate information may result in my application being disqualified. 

- I hereby authorize the release and use of all information pertaining to me for the purpose of obtaining the most qualified services available to help me. I agree to release from all liability and responsibility all persons and entities requesting or supplying such information. I realize that all information is to be used for the sole purpose of helping me in my recovery process and reestablishing myself in the future. 

- I understand that from time to time, the Will Bright Foundation may use my name, likeness, and or picture for testimony and marketing purposes, and I authorize such use. 

- I acknowledge that I have read and understand all the statements that are made herein.

Print Name:

Text field

Signature:

Signature

Date: Date