One Step

RJM House/RJM Upon Awakening Application

General

Tell us about yourself

What is your first name?

What is your middle name? No middle name? Move on to the next question.

What is your last name?

When is your birthdate?

What is your race/ethnicity?

What is your gender?

What is your marital status?

Are you a veteran?

Contact Information

How can we reach you?

*If you do not have a phone number or email address, please leave these fields blank. If you wish to provide other contact information where you can currently be reached, you may add those contacts below in the next section. Thank you!

What is your email address?

At what phone number can we best reach you at?

Street Address:

City:

State:

Zipcode:

Contacts

Recovery is a team effort. Please provide the contact information for your support network and other stakeholders in your recovery. Be sure list and list the following:

1) Emergency Contact (at least one);

2) Referent listed above;

3) Any care providers and stakeholders in your recovery, including Probation/Parole.

(Provide as much contact information as may be available to you)

Contact #1
name:
phone:
email:
type:
Contact typeDon't see the option you're looking for? Click here
notes:

Insurance

Enter your insurance provider(s).

Insurance #1
Client insurance provider:
Client insurance plan:
Client insurance group ID:
Client insurance policy #:
Client insurance other:

Medical History

Tell us about your medical history.

When was your last relapse date?

Recovery History #1
sobriety date:
relapse date:

What is your substance(s) of choice? Add multiple by clicking in the box and selecting different options

Substances of choice

Have you been clinically diagnosed with anything? Add multiple by clicking in the box and selecting different options

Diagnosis

Do you have any health problems? Add multiple by clicking in the box and selecting different options

Health Problems

What kind of meetings do you attend? Add multiple by clicking in the box and selecting different options

Substances of choice

What allergies do you have? No allergies? Move on to the next question.

Have you had any of the following tests?

Medical Tests #1
type:
TypeDon't see the option you're looking for? Click here
performed_on:
notes:
result:
ResultDon't see the option you're looking for? Click here

Medications

List the medications you are currently prescribed.

Medication #1
Name:
Dosage:
Quantity:
Category:
Choose category...Don't see the option you're looking for? Click here
Frequency:
Md:
Notes:
Pill count:
Discontinued at:

Treatment Centers

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

Treatment Center History #1
name:
address:
city:
state:
zip:
started:
ended:
notes:
type:
Treatment center typeDon't see the option you're looking for? Click here
reason for discharge:
Treatment center reason for dischargeDon't see the option you're looking for? Click here

Client Referral Source

Who referred you to us?

Sober Living History

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

Sober Living History #1
name:
description:
address:
city:
state:
zip code:
admitted:
discharged:
estimated length of stay:
reason for discharge:
Sober living reason for dischargeDon't see the option you're looking for? Click here

Employment

Tell us about your employment status.
If you're currently unemployed select "unemployed" under "type"

Employment History #1
Employer name:
Employment position:
Employment income:
Employment incomeDon't see the option you're looking for? Click here
Employment started:
Employment ended:
Employment type:
Employment typeDon't see the option you're looking for? Click here
Employment notes:

Living Arrangement

Tell us about your living arrangement prior to moving into this facility

Living Arrangement History #1
arrangement:
Living arrangementDon't see the option you're looking for? Click here
started:
ended:
notes:

RJM HOUSE LLC will consider all requests for reasonable accommodations. To submit a request for reasonable accommodation due to a disability, please submit a request in writing to the operator separately from this application. You may request a reasonable accommodation request form from the operator at rjmrecovery@gmail.com.

PLEASE CALL OUR INTAKE LINE UPON COMPLETING THIS APPLICATION AT 603-836-4031 TO SCHEDULE YOUR PHONE SCREENING. APPLICATIONS WILL NOT BE CONSIDERED UNTIL YOU CALL OUR INTAKE LINE TO SCHEDULE PHONE SCREENING. WE LOOK FORWARD TO SPEAKING WITH YOU.

Applicant signature

RJM House/RJM Upon Awakening Application

Tell us about yourself

Contact Information

How can we reach you?

Contacts

Contact #1

Insurance

Enter your insurance provider(s).

Insurance #1

Medical History

Tell us about your medical history.

Recovery History #1

Medical Tests #1

Medications

List the medications you are currently prescribed.

Medication #1

Treatment Centers

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

Treatment Center History #1

Client Referral Source

Sober Living History

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

Sober Living History #1

Employment

Tell us about your employment status. If you're currently unemployed select "unemployed" under "type"

Employment History #1

Living Arrangement

Tell us about your living arrangement prior to moving into this facility

Living Arrangement History #1

Tell us about your employment status.
If you're currently unemployed select "unemployed" under "type"