Ozark Recovery Housing
Welcome to the Ozark Recovery Housing application wizard
Click next to begin!
General
Tell us about yourself
What is your first name?
Client first name
What is your middle name? No middle name? Move on to the next question.
Client middle name
What is your last name?
Client last name
When is your birthdate?
Client birthdate
What is your race/ethnicity?
Client race
What is your gender?
Client gender
What is your marital status?
Client marital status
Are you a veteran?
Client veteran status
Highest Level of Education?
Text field
Contact Information
How can we reach you?
What is your email address?
Client email
At what phone number can we best reach you at?
Client phone
Street Address:
Client Address
City:
Client City
State:
Client State
Zip Code:
Client Zip
Contacts
Give us a few people that we can reach out to in case of an emergency.
Contact
Medical History
Tell us about your medical history.
When was your last relapse date?
Recovery history 1 relapse date
What is your substance(s) of choice? Add multiple by clicking in the box and selecting different options
Client substances of choice
Have you been clinically diagnosed with anything? Add multiple by clicking in the box and selecting different options
Client diagnosis
Do you have any health problems? Add multiple by clicking in the box and selecting different options
Client health problems
What kind of meetings do you attend? Add multiple by clicking in the box and selecting different options
Client kinds of meetings attended
What allergies do you have? No allergies? Move on to the next question.
Client allergies
Have you had any of the following tests?
Medical Tests
Medications
List the medications you are currently prescribed.
Medication
Treatment Centers
Tell us about any treatment centers you've previously been admitted into.
TreatmentCenterHistory
Client Referral Source
Who referred you to us?
Client Referred By
Sober Living History
Tell us about any sober livings you've previously been admitted into.
SoberLivingHistory
Employment
Tell us about your employment status.
If you're currently unemployed select "unemployed" under "type"
EmploymentHistory
Living Arrangement
Tell us about your living arrangement prior to moving into this facility
LivingArrangementHistory
Funding Source
Do you have a RSS Housing Voucher through Region 1 Access Site?
Dropdown
If NO, you must contact Region One Access Site (Healing House) at 816-768-8606 for assessment and intake.
Can you pay the $150 Deposit on Admission (not covered by the RSS voucher)?
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Waiver of Liabilities
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.
Signature
PROGRAM PARTICIPANT WAIVER OF LIABILITY
I release Ozark Recovery Housing as an organization, its administrative staff, or any program support service provider from any liability due to personal physical or mental injury while staying at the Men’s/ Woman's House. This pertains to any injury while on the property, or while being transported in any organizational or staff personal vehicle.
Signature
RELEASE OF INFORMATION
I hereby authorize the release of information I understand that information will be communicated verbally and or in written form. Information concerning psychiatric, psychological, medical diagnosis, drug or alcohol abuse, economic status, and educational information will be released and/or communicated if indicated below. I authorize the following information to be released to Ozark Recovery Housing LLC.
• Treatment Plans
• Substance Abuse Treatment Records
• Treatment / Discharge Summaries
• Social and/or Developmental History
• Health / Medical Records
• Restorative Support Services Academic / School-related Record
• Social Support Services (Food, Clothing, Shelter)
• Grades and Test Scores
• Attendance receive this information, specific individuals must be named
• Suspensions / Expulsions above
• Exceptional Student Education / Section 504 records
• Other : Probation and Parole
-Current sober living provider
I acknowledge that all information I authorize to be released or requested will be held strictly confidential. I understand this authorization will expire one (1) year after the date signed.
Signature
PROGRAM PARTICIPANT PERSONAL PROPERTY WAIVER OF LIABILITY
Initials Text field I agree to accept full responsibility for any personal property, I have been advised to not bring any item of sentimental or significant monetary value into Ozark Recovery Housing LLC because of risk of loss or theft.
Initials Text fieldI agree to hold the Ozark Recovery Housing LLC staff harmless or responsible in any way, shape, form and/or fashion, from any and all losses I may have, from theft or otherwise. I understand that my belongings are not insured unless I obtain my own insurance policy at my own cost.
Initials Text fieldUpon leaving, Ozark Recovery Housing LLC for any reason whatsoever, I will immediately remove my personal belongings at the time of discharge. Ozark Recovery Housing LLC does not store any items for any reason beyond discharge, and it is for this reason that residents are advised to not bring in more items than they can carry out within one hour. All personal belongings left behind after 24 hours will be donated without compensation on the 25th hour.
Signature
HOUSING ACKNOWLEDGEMENT
Ozark Recovery Housing LLC, through its’ transitional living program, provides housing as a part of the program and in no way implies the establishment of residency. Participants in the program are permitted to utilize the housing provided by Ozark Recovery Housing LLC for a monthly fee. In order for the participant to retain housing as a part of their program, they must follow and adhere to all housing guidelines and program policies and procedures. In the event a participant in the program violates any provision that requires immediate removal, their caseworker will be notified for pick-up and they will be removed
Signature
MANDATORY PROGRAM PARTICIPATION ACKNOWLEDGEMENT
Ozark Recovery Housing LLC requires each of its’ participants to enroll in affiliate programs that provide supportive services. If Ozark Recovery Housing LLC has agreements with local agencies that provide workforce development, job readiness, substance abuse support, transportation, education and training, and food, qualified participants are required to enroll. Our agreements support the transitional living program and participation is mandatory.
Signature
HOUSE MEETING ACKNOWLEDGEMENT
All individuals participating in the Ozark Recovery Housing LLC's transitional living program are required to attend weekly/monthly house meetings and groups. These meetings are designed to ensure proper communication channels are open with participants and staff. Attendance is required.
Signature
MEDICATION ACKNOWLEDGEMENT
All participants who are prescribed medication by a medical doctor are required to adhere to the directions of their doctor. If medication regiments are not followed, it can be grounds for immediate removal at the discretion of management.
Signature
When you have completed the application, please go to our website and book a screening--scroll to the bottom of the website www.ozarkrecoveryhousing.com and selet "BOOK NOW" for a virtual application screening. You will be called within the timeframe that you choose (appointment is by phone). If you are a respite client (under 30 days sobriety) and need a screening sooner, please call our intake line 816-808-2233. Signature