Irongate Recovery, its owners, operators, directors, staff, or volunteers do not discriminate against individuals entering the program. We believe any individual should have the opportunity to live in a recovery residence and recover from addiction to drugs and alcohol. Irongate Recovery does not discriminate based on race, color, national or ethnic origin, sexual orientation, HIV status, gender, age, education level, socioeconomic status, religion, lack of religion, or qualified disability (except for those disabilities that would prevent the individual from being able to participate in Irongate Recovery program requirements)
I, Client first nameClient middle nameClient last name am applying to participate in a recovery living program at Irongate Recovery on Date. I am aware this residence promotes recovery and supports healing. As a member of this community, I will respect the cohesiveness of the residence and will NOT have items that could cause me or others harm.
DOB: Client birthdate
Gender: Radio buttons
Race: Client race
Ethnicity: Client ethnicity
SSN: SSN
Phone Number: Client phone
Email: Client email
Date Housing Needed: Date
Current Living Situation: LivingArrangementHistory
Education Level: Dropdown
How did you hear about Irongate? Dropdown
If you were referred to us, who referred you? Client Referred By
Substance Use History
When did you last use drugs or alcohol? Date
Substance(s) of Choice: Client substances of choice
Do you have prior recovery experience? Dropdown
Have you ever worked steps? Dropdown
Do you have a sponsor? Client sponsor
Have you ever been to 12-step meetings? Client kinds of meetings attended
Medical History
Have you had any past surgeries that resulted in metal in your body or artificial limbs, etc.? Dropdown
If so, please describe: Text field
Do you have any allergies? Animals, bleach, grass, bees, latex, etc.? Dropdown
If so, please describe: Client allergies
Do you have medical Insurance? Dropdown
If so, please describe: Insurances
Do you currently receive any state or federal benefits like food stamps, unemployment, disability, or social security? Dropdown
If so, please describe: Text field
Do you suffer from any diagnosed mental illness? Client diagnosis
Do you have a continuing care plan from a Mental Health Agency? Dropdown
If so, which Agency? Text field
Please describe your mental health recommendations from that agency. (example: IOP, MAT, individual therapy, check-ins, etc.): Text field
Who is your therapist or case manager from that Mental Health Agency? Contact
Do you suffer from any medical conditions? Dropdown
If so, please describe: Client health problems
Are you currently taking any prescribed medications? Dropdown
If so, please list all medications: Medication
Family History
Marital Status: Client marital status
Do you have any Children? Radio buttons
If so, how many? Dropdown
Are your children in a safe environment? Dropdown
Are you currently pregnant or think you might be pregnant? Radio buttons
Do you have supportive family members or friends? Radio buttons
If so, please describe: Family Members
Employment History
Are you currently employed? Dropdown
If you are currently employed, where do you work? Text field
If you are currently unemployed, do you have financial support? Dropdown
If so, please describe: Text field
Military Service History
Have you ever served in the Military? Dropdown
If so, which Branch? Text field
Please describe dates of service and discharge status below:
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Other Information
Do you have a valid driver’s license, state-issued ID, or Passport? Dropdown
Do you have a copy of your birth certificate or SSN? Dropdown
Is English your primary language? Dropdown
Were you born in the United States or one of the US Territories? Dropdown
Criminal History
Have you ever been convicted of a DUI, DWI, or any other driving-related crime? Dropdown
Have you ever been convicted of arson? Dropdown
Are you on the SO registry? Dropdown
Have you ever been convicted of any felony or misdemeanor? Dropdown
If so, please list your charge(s) below:
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Are you currently on probation or parole? Dropdown
If so, who is your supervising Officer? Text field
Please list their contact information below:
Contact
Do you currently participate in any judicial programs like recovery court, tnrocs, or drc? Dropdown
If you have a case manager, please list their contact info below:
Contact
Please describe any current ongoing legal issues such as having an open case with DCS, any future court dates, or possibly having an open warrant, etc.
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Please use the box below to describe any other information you want us to know about your situation:
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