Date of Application: Date

Personal Information:

First Name: Client first name

Middle Name: Client middle name

Last Name: Client last name

Date of Birth:Date

Social Security Number: SSN

Marital Status: Checkboxes 

Current Living Situation: Text field

Last Known Address: Client Address

Email Address: Text field

Primary Phone Number: Client phone

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: (Please select all that apply) Checkboxes

Level of Education Completed:Checkboxes

Denomination Affiliation: Text field

Military Service History: Checkboxes

Legal History:

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 fieldDate: DateCounty: Text fieldCourt Date: Date

Charge: Text fieldDate: DateCounty: Text fieldCourt Date: Date

Have you ever been incarcerated in prison or jail? Checkboxes

If yes, please list the most recent instances:

Facility: Text fieldDates of Incarceration: DateDate 

Duration: Text field

Facility: Text fieldDates of Incarceration: DateDate 

Duration: Text field

Have you been convicted of a felony? Checkboxes

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

Are you a registered sex offender? Checkboxes

Substance Use History:

Primary Substance of Use: Text field

Secondary Substance of Use:Text field

Age of First Use (Primary Substance): Text field

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

If yes, please describe: Paragraph

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

If yes, please list: Paragraph

Have you ever received mental health counseling or therapy? Checkboxes

If yes, when and for what reason? Paragraph

 

Recovery and Treatment History:

Have you previously attended any substance use treatment programs (e.g., detox, residential, outpatient)? Checkboxes

If yes, please list:

Program Name/Location: Text field

Dates Attended: DateDate 

Completed? Checkboxes

Program Name/Location: Text field

Dates Attended: DateDate 

Completed? Checkboxes

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? Checkboxes

If yes, please list their relationship to you: Text field

Do you have a vehicle? Checkboxes

Do you have a valid driver’s license? Checkboxes

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

If yes, please describe: Paragraph

 

Functional Assessment:

Are you able to independently manage your personal hygiene? Checkboxes

Are you able to prepare your own meals? Checkboxes

Residential Program Applicants Only:

Can you get along with others in a residential environment?  Checkboxes

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

If employed, are you able to perform your job duties? Checkboxes

Do you have any physical limitations that may affect your ability to participate in program activities or work? Checkboxes

If yes, please describe: Paragraph

Identification:

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

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