ASSOCIATE RECOVERY COMMUNITIES

FARR Certified Recovery Residences

Administrative Offices

 318 South Betty Lane Clearwater, Fl 33756      

Office: (727)754-5790        Fax: (727)754-4226

 

NEW CLIENT ASSESSMENT FORM

 ***PLEASE CLICK SAVE FORM FOR LATER TO SUBMIT THIS FORM***

 

 

Date:  Date

 

Name:  Client first nameClient last name

 

Phone:  Client phone

 

If you do not have a phone how and when do you plan to get one? Here at ARC, we utilize One Step Software as our recovery platform. Text field

 

Email:  Client email

 

Address:  Client Address

 

City:  Client City

 

State:  Client State

 

Zip:  Client Zip

 

Gender:  Client gender

 

DOB:  Client birthdate

 

Race:  Client race

 

Veteran:  Client veteran status

 

Marital status:  Client marital status

 

Medications:  Medication

 

Mental Health Diagnosis:  Client diagnosis

 

Health Problems:  Client health problems

 

Emergency Contact:  Contact

 

 HISTORY

Are you currently out on bond? Text field

 

Pending charges: Text field

 

Current Probation:Text field

 

Have you ever been convicted of any violent or sexual charges: Text field

 

Employment History:  EmploymentHistory

 

Education:  EducationHistory  Client school

 

Substances of Choice:  Client substances of choice

 

Last Date of Use:  Date  Substance(s) Used:  Text field

 

Are you currently prescribed Medical Assisted Recovery medications? Text field What medication?Text field

 

Are you willing to sign a release of information allowing us to communicate with your doctor regarding your MAR medication?Text field

 

Treatment Center History:  TreatmentCenterHistory

 

Sober Living History:  SoberLivingHistory

 

Estimated Length of Stay at ARC:  Client estimated length of stay

 

How do you plan to get to a recovery meetings, work, and daily activities current form of transportation  :

Walk:Text field

Bike:Text field

Bus: Text field

Vehicle:Text field

 

Have you ever participated in A.A. or N.A.?   Checkboxes 

 

Our Current Program Fees are $100 admin fee and $225 a week. $325 to move in and then $225 weekly there is a $25 late fee 

What is your current funding coming into our program:

Self Pay:Text field

Family Support:Text field

State Funded:Text field

Other:Text field

 

How do you feel ARC can help guide you in your recovery? :Paragraph

 

 

 

Signature:  Signature Date: Date

 

Witness:Signature Date :Date

Notes: Paragraph

 

***PLEASE CLICK SAVE FORM FOR LATER TO SUBMIT THIS FORM***