A Different Way
Todays Date:Date
Date needing bed Date
Name: Client first nameClient middle nameClient last name
DOB: Client birthdate
Social Security Number: Text field
Previous Address: Client Address Client CityClient StateClient Zip
Phone Number: Client phone
Email: Client email
Gender: Client gender
Race: Client race
Marital Status: Client marital status
Veteran: Client veteran status
Maiden Name: Text field
Do you have children under 18 Text field if yes how many Text field
Emergency Contact
Name:
Text field
Phone Number:Text field
Relationship?Text field
Do you have insurance?
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Do you have a Primary Doctor? If so name and number:Text field
Do you need county funding?
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Have you recieved county funding in Delco from prior July until now? If yes how long?Text field
What IOP will you be attending? Text field
Do you need a referral for outpatient therapy?
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Insurance InformationInsurances
Current treatment center Text field
Discharge Date: Date
Drug of choice: Client substances of choice
Date of last use Date How much Text field
What is your clean date?
RecoveryHistory
Have you overdosed recently?
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If yes the date
Date
Do you have an opiate history?
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Are you an IV user?
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Are you on MAT medication?(It is required for opiate history)
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MAT medication Text field
Are you on any additional medication?
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If yes what are they prescribed for?Text field
Are you a former ADW resident?
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If yes which house did you live in and reason for discharge? Text field
Are you a Deleware county resident?
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Do you revieve foodstamps?(Food is not provided, if you answered no arrangements for food will need to be made prior to arrival)
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Are you an out of state resident?
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Are you allergic to cats?(Each recovery house has one)
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Criminal History
Are you currently on Probation or Parole?
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If Yes Agents Name: Text field
Agents Phone Number: Text field
Do you have any warrants?
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Were you ever convicted of a crime involving Megans Law or sex offender crimes?
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Were you ever convicted of assault?
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Do you have any physical restrictions? (that would prevent you from climbing stairs, doing chores, having a top bunk?)
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Education(Highest grade completed?)Text field
Religion:Text field
Are you a smoker?Text field
In your own words what brought you to A Different Way and what are you exspecting to get from program?Paragraph
Please provide the email for the counselor handling your discharge.(This is needed for communication, if left blank we Can Not respond to your application)Text field
Disclaimer ADW staff are not present in the home 24/7. House coordinators are senior residents that facilitate the daily operations of the house. We cannot accommodate housing for individuals that cannot function successfully and independently in a self help setting. ADW residents are not handicap accessible. ADW staff do not administer medications, nor do we have medical staff.
Do you have a history of paranoia, psychosis, hallucinations, hearing voices, suicidal or homicidal ideations or attempts?
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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.
I Text field, consent that the answers I provided A Different Way are the truth to the best of my knowledge. I understand that the information provided is confidential and A Different Way will not share this information with any outside organizations.
Signature: Signature
Date: Date
Once the application is reviewed, A Different Way representative will contact you if you were able to offer you residency at this time. If you are accepted into ADW, a welcome letter will be sent with the address and instructions for your arrival date. Please review this letter prior to your discharge. Please review this letter prior to asking questions, as the letter may answer the questions you may have. If you have not recieved your welcome letter, please request a copy from the staff person coordinating your aftercare. It is your responsibility to ensure that you have the information provided.