Applicaiton

 One12 Recovery

At, One12 Recovery, located in Chattanooga, Tennessee, we pride ourselves in supporting women on their recovery journey and emphasizes four core principles known as the Four C's:

Choice: Recovery is a personal choice and One12 empowers women to take ownership of their journey. This means recognizing the power they have to choose sobriety and a life free from addiction.
Connection: No one recovers alone One12 fosters a strong sense of connection through supportive communities and peer relationships. Women can share experiences, offer encouragement, and learn from each other's journey.
Courage: Facing addiction and pursuing recovery takes immense courage. One12 celebrates the bravery it takes to confront challenges and embrace a new life. 
Change: Recovery is a transformative process. One12 emphasizes the importance of personal growth and change, both internally and external circumstances.
 

These core principles provide a foundation for women in recovery to build a new life of empowerment, connection, and lasting change.

If you are ready to make One12 Recovery your home then you are also committed to making a total life change and we are so greatful you are choosing to take this next step in your recovery journey with us.

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
What documents do you have on you?
ID, Social Security Card, Birth Certificate 
Client notes
Do you have a vehicle? If sp what is the make, model, and tag number?
Client notes

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
Zipcode:
Client Zip

Contacts

Give us atleast 3 people that we can reach out to in case of an emergency.

Contact

Insurance

Enter your insurance provider(s).

Insurance

Medical History

Tell us about your medical history.
Have you been clinically diagnosed with anything? Only choose options you have a clinical dianosis for! Add multiple by clicking in the box and selecting different options
Client diagnosis
Do you have any health problems? 
Client medical notes
What allergies do you have? No allergies? Move on to the next question.
Client allergies
 

Medications

List the medications you are currently prescribed.

Medication

Treatment Center History

Tell us about any treatment centers you've previously been admitted into.

TreatmentCenterHistory
 Are you currently on MAT?
Medication
What are your recovery goals with MAT?
Client notes

Client Referral Source 


Who referred you to us?
Client Referred By
 
Who is covering the cost of your entry fees? Please list the person or agency and their phone number; If you are paying just type self.
Client notes

Occupancy 


What facility will you be staying at?
Client facility
What date will the you be admitted on?
Client admit date
What is the estimated length of stay?
Client estimated length of stay
 

Recovery Journey and History

Tell us about any sober livings you've previously been admitted into.

 
RecoveryHistory
What is your motive for seeking recovery residency?
Client notes
What is your substance of choice?
Client substances of choice
Have you ever stayed in a  sober living environment before? If so where and how long?
SoberLivingHistory
Do you attend 12 step meetings and what type of meetings do you attend?
Client kinds of meetings attended
Do you have a sponsor?
Client sponsor 
Do you have any pending court charges and if so what are they and for what county?
Client notes
Please list all your past criminal charges
Client notes
What can One12 Recovery do to help you achive some of your recovery goals?
Client notes
 

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