Clean Haven Recovery Residence Application 

 

Name: Client first nameClient last name

Date of Birth: Client birthdate

Email: Client email

Phone: Client phone

 

What Facility are you being treated at: Text field

Case Manager/Discharge Planner Name, Phone, and Email: 

Therapist/Clinician

Best way to get back in touch with you: Text field

What is your discharge date: Date

 

When and where have you been treated for substance abuse in the past: 
Paragraph

Have you ever lived at a recovery residence? 
Checkboxes

What is the longest length of sobriety that you've had: Text field

From what city and state will you be moving: Text field

Do you have a valid Driver's license and do you currently have possession of it? 
Checkboxes

Do you have a state ID, and do you currently have possession of it?
Checkboxes

Do you have a social security card, birth certificate, or passport and do you currently have possession of any of these? 
Checkboxes

What state were you born in? Text field

Primary Substance of Choice: 

Client substances of choice

Date of Last Use: Date

Secondary Substance of Choice: Text field

Date of Last Use: Date

Will you be attending Outpatient Treatment (IOP): 
Checkboxes

How many times have you attended inpatient treatment: Text field

How many times have you attended outpatient treatment: Text field

Are you seeking residence at Clean Haven of our own volition or is this residency recommend by probation or TDOC: Text field

Have you worked a 12-step program: 
Checkboxes

Do you have any pre-existing mental, emotional, and/or physical conditions: 
Checkboxes

Are you on disability or are there any reasons why you can't work? Text field

 

List all medications are you currently taking taking: 

Medication

 

Do you have a legal vehicle that you drive: 
Dropdown

Do you have insurance and is the vehicle registered/up to date: 
Dropdown

Do you have a job: 
Dropdown

What is your job title and description: Text field

Do you have any pending charges, court dates, or outstanding warrants: 
Radio buttons

Do you have any children: 
Checkboxes

Will you need to apply for food stamps or renew any forms of identification: 
Checkboxes

What are your motives for seeking recovery residency: 
Paragraph

What is your expected length of stay at Clean Haven: Text field

Who will be covering the cost of your lease at Clean Haven, you or someone else?
Dropdown

If someone else.... 

Payer Contact Name: Text field

Payer Contact Number: Text field

 

My signature below confirms my understanding and agreement to the following terms: 

I must be fully detoxed and able to pass a drug screen and breathalyzer upon my arrival to Clean Haven Recovery Residences. 

I agree to abstain from mood-altering substances, which can result in injury, coma, or death during my residency. 

I agree to my weekly random drug and alcohol screens. 

I understand that any violation, on my behalf, of Clean Haven Recovery Residences' zero tolerance policy for drug and alcohol use, will result in my immediate dismissal/step up in treatment. 

I also understand and agree to pay the financial requirements upon my arrival and throughout my residency at Clean Haven Recovery Residence. 

My signature below verifies that this application was accurately completed by: Date

Signature