I hereby apply for membership in the Continuum Recovery Network (CRN) and provide the following information for use in determining my eligibility for membership. 

 

Name Client first nameClient last name

Date of Birth  Client birthdate                   Social Security SSN

Address Client Address

City Client City  State Client StateZip Client Zip

Telephone Home Client phone  Cell Phone Client phone

EmailClient email

 

Employer Text field

Phone Contact

 

Insurance

Provider _______________________________________

Member ID _________________________   Group Number _____________________________

Prescription Drug Plan

RXBin _______________________________              RxPCN ______________________________

RxGRP _______________________________             ID _________________________________

 

Vehicle Information

Drivers License Number Text field

Year Text field   Make  Text field

Model  Text field Color  Text field

Car Insurance Provider  Text field

No car Text field

 

Medications

______ Continuum Recovery Network follows all state and federal guidelines regarding MAT/MAR protocol including methadone, buprenorphine, and naltrexone.   I understand and agree that all medications must be approved by staff.  This includes all prescriptions or over-the-counter medications that may become necessary throughout my stay at Continuum Recovery Network.   There are no exceptions to this agreement.  

List all medications

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Finances

Initials Text field I agree to pay a one-time non-refundable application fee of $150. 

Initials Text fieldI agree to pay $325 a week

Initials Text fieldI understand that the application fee plus first week fees are to be paid prior to entry

Initials Text fieldI understand that program fees are due each week on Friday by 5pm

Initials Text fieldI understand and agree that if I fall behind more than 1 week on my program fees, I will be referred to a more suitable/appropriate residence.

Initials Text fieldI understand that dismissals/exits are under the discretion of CRN management and the resident and are final with no refunds.  Once a resident is asked to leave, CRN is released of any and all liability or responsibility.

If you’re program fees will be paid by a beneficiary (family member/outside sources), please provide contact details

Name Text field

Phone Client phone Email Client email

Initials Text field I give permission for Continuum Recovery Network to contact/receive calls or emails for communication purposes with my beneficiary.

Emergency Contacts

Initials Text field I give permission for Continuum Recovery Network to contact my emergency contacts for any and all emergencies, or after being consulted, for any general issues deemed as a barrier to my improved mental and physical well-being.

 

Name Text field

Phone Client phone Relationship Text field

Name Text field

Phone Client phone Relationship Text field

 

Recovery

Drug of Choice: Text field   Recovery DateDate

Do you have a sponsor Checkboxes      

Sponsor NameText fieldPhone Client phone

 

What are the "Key Ingredients" of your recovery program?

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Have you been in a substance use treatment center (residential/inpatient or outpatient) within the last 3 years?      List the name of each program and dates attended.

Text field Date _____________________

Text field Date _____________________

Text field Date _____________________

Text field Date _____________________

Text field Date _____________________

By signing this document, I agree and understand all information is accurate and truthful. 

 

SignatureSignature Date Date