Tribe Recovery Homes Intake Questions

Tribe Recovery Homes LLC. Intake Questions

1. Participant information:

First Name: Client first name 

Middle Name: Client middle name 

Last Name: Client last name

Gender: Client gender Birthdate: Client birthdate

Previous/Family Members/Partners Street Address:

Address: Client Address

City: Client City State: Client State Zip: Client Zip

Sobriety Date: Client sobriety date

Place of employment: 

Employer: Employer 2 name Position: Employment 2 position

Length of employment: Started: Employment 2 started Ended: Employment 2 ended

Social Security#: Text field

E-mail: Client email

Highest level of education completed:

Education 1 degree

Cell phone:  Client phone


Please indicate which method of contact is preferred and if it is ok to leave a message:

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Emergency Contact Info Including Contact Number:

Name: Contact 1 name Phone: Contact 1 phone


2. Have you dealt with any of the following emotional / behavioural problems? Check all that apply:

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If "other(s)", please specify:

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3. Have you received help for drug or alcohol dependency? If yes, please specify when, for what and where:

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4. How have you been coping with staying sober until now?

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5. What support do you have in your life (Family / Sponsor / Recovery Coach / Friends / School / Work / Social
activities, etc)?
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6. Which - if any - of these substances do you currently use or have used in the past? Please use the box to indicate
your age at first use and age at last use. (E.g.: Alcohol - 16, 30)

Checkboxes Alcohol
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Checkboxes Amphetemines
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Checkboxes Opiates
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Checkboxes Heroin
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Checkboxes Methamphetamine
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Checkboxes Barbiturates
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Checkboxes Caffeine
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Checkboxes Cocaine
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Checkboxes Crack cocaine
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Checkboxes Hallucinogens (e.g., LSD)
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Checkboxes Inhalants (e.g., glue, gas)
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Checkboxes Marijuana or hashish
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Checkboxes Nicotine/cigaretters
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Checkboxes PCP
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Checkboxes If "other(s)", please specify
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7. Is there a history of alcohol/drug abuse in your family? Please use the box below to indicate the type of drugs and if the abuse is active or in remission:

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If "other(s)", please specify

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8. Have you received psychotherapy or counseling in the past? If yes, when was that? Please list the mental health care
providers (Counselor / Psychologist / Psychiatrist)' names and phone numbers:

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9. If any, which have been the consequences of substance abuse in your life? Please use the box below to explain such
consequences:

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If "other(s)", please specify
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10. Describe your current physical health:
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11. If you are currently under care of a Physician, please specify:

Physician: Condition: Treatment:
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12. Which medications (psychotropic or not) are you currently taking?

Medication #3

Medication: Medication 1 name Dosage: Medication 1 dosage

Quantity: Medication 1 quantity Category: Medication 1 category

Frequency: Medication 1 frequency MD: Medication 1 md

Pill count: Medication 1 pill count Discontinued at: Medication 1 discontinued at

Adverse effects: Medication 1 notes

Since when: Text field

Medication #2

Medication: Medication 2 name Dosage: Medication 2 dosage

Quantity: Medication 2 quantity Category: Medication 2 category

Frequency: Medication 2 frequency MD: Medication 2 md

Pill count: Medication 2 pill count Discontinued at: Medication 2 discontinued at

Adverse effects: Medication 2 notes

Since when: Text field

Medication #3

Medication: Medication 3 name Dosage: Medication 3 dosage

Quantity: Medication 3 quantity Category: Medication 3 category

Frequency: Medication 3 frequency MD: Medication 3 md

Pill count: Medication 3 pill count Discontinued at: Medication 3 discontinued at

Adverse effects: Medication 3 notes

Since when: Text field

Medication #4

Medication: Medication 4 name Dosage: Medication 4 dosage

Quantity: Medication 4 quantity Category: Medication 4 category

Frequency: Medication 4 frequency MD: Medication 4 md

Pill count: Medication 4 pill count Discontinued at: Medication 4 discontinued at

Adverse effects: Medication 4 notes

Since when: Text field

 

13. What is your current employment situation? Check all that apply:

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If "other", please specify

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14. If currently employed:
What is your occupation?

Employer: Employer 1 name 

Do you enjoy your work?

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How many hours a day do you work?

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Do you take work home with you?

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15. How is your social interaction? Check all that apply:

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If "other", please specify
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16. What is your current financial situation? Check all that apply:

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If "other", please specify:

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17. What is your legal situation? Check all that apply:

Checkboxes

Please Explain Each Answer Checked
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18. If you are on Parole or Probation, please provide the following:
Location Of Parole/Probation:

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Parole/Probation Officer Name:

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Parole/Probation Officer Phone Number:

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Parole/Probation Officer Email Address:

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19. Please Provide Provide Insurance Information:

Insurance Type: (Medicaid, Medicare, Private Insurance):

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If Private Insurance Please Provide Details:

rovider: Client insurance provider Insurance Plan: Client insurance plan

Group ID: Client insurance group ID Policy#: Client insurance policy #


20. On average, how many hours a week do you spend...
Driving / Commuting:

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Reading:

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Watching TV / Video games:

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Using the computer:

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21. Relationship status:

Client marital status

If "other", please specify:

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22. What are your passions and leisure pursuits?

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23. What is your current level of stress?

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24. How do you cope with stress?

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25. What are the major causes of your stress? (Marital / Financial / Career / Family / Health / Unfulfilled expectations,
etc)

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26. Do you exercise? If yes, what type of exercise, how often and for how long, in average?

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27. Drugs Used During Lifetime

How
Often
Have You
Used The
Following
Drugs:
Primary
Drug Of
Choice
Multiple
Times
Once Never
used
Methamphetamine Text field Text field Text field Text field
Opiates/Heroin Text field Text field Text field Text field
Crack/Cocaine Text field Text field Text field Text field
Barbiturates Text field Text field Text field Text field
CBD/Marijuana Text field Text field Text field Text field
Alcohol Text field Text field Text field Text field
Steroids Text field Text field Text field Text field
Amphetamines Text field Text field Text field Text field
PCP Text field Text field Text field Text field
Benzodiazepines Text field  Text field  Text field  Text field 
 Kratom Text field  Text field  Text field  Text field 

 

28. How Long Have You Been Clean & Sober

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29. Have You Ever Been On Any Form Of Medicated Assisted Treatments If So Check The Following Treatments You've
Used
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30. How Many Times Have You Been In Inpatient Treatment

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31. How Many Sober Livings Have You Lived In

Checkboxes


32. Why Did You Leave Your Last Sober Living

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33. After A Full Detoxification Period How Many Times Have You Relapsed

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Participant Signature:

Signature

 

Confidentiality Agreement

The Confidentiality of recovering persons living in a supportive living environment can be protected under
Federal Law 42CFR, which protects residents from anyone outside of said program having knowledge of
their participation in the program without the resident’s specific consent. No information regarding a
resident of Tribe Recovery Homes LLC. May be released to anyone outside of the program unless:

1. The resident has signed a consent form to the requesting party i.e. person/agency.
2. A court order is issued to Tribe Recovery Homes LLC. Regarding information on said resident.
3. Medical personnel require the information in a medical emergency.
4. The resident threatens to harm him/herself or someone else


Federal Law does not protect a resident if they commit a crime against anyone at Tribe Recovery Homes
LLC. or outside of the program, Also Federal Law does not restrict sharing of information regarding
reported child abuse/neglect to appropriate state & local authorities. These Laws apply not only to
residents also the staff, board members and volunteers of Tribe Recovery Homes LLC.


I,Text field, Agree to not reveal to anyone outside of Tribe Recovery
Homes LLC. The name, identity or description of another resident. I also agree to not discuss the content
of conversations or groups with anyone outside of Tribe Recovery Homes LLC. This includes sharing at
recovery meetings. I agree to inform staff if any peers reveal any information about themselves or another
resident that may be a cause for concern.

Anti Defamation Clause

In the interest of the privacy and respect of TRS residents, staff and services, we require all residents to
maintain confidentiality of all property info, resident info, and service info.
TRS also requires all residents to refrain from public defamation, slander, or any negative commentary in
public forums, whether electronically or otherwise.
Any information made public will be grounds for immediate expulsion from the property and the program.

Participant Signature:

Signature

Date: Date

Signature:

Signature

Date: Date

Witness Signature:

Signature

Date: Date

 

Release of Information

HIPPA Privacy Authorization Form **Authorization for use or disclosure of protected health information
(Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164) **

1. I Text field Authorize:

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To use and disclose the protected health information described below to Tribe Recovery Homes LLC.

1. This authorization for release of information covers the period of health care from: all past, present
and future periods.

2. This medical information may be used by the person I authorize to receive this information for
medical treatment or consultation, billing or claims payment, or any other purposes as I may direct

3. This authorization shall be in force and effect until I leave Tribe Recovery Homes LLC. At which time
this authorization expires.

4. I understand I have the right to revoke this authorization, in writing at any time. I understand that a
revocation is not effective to the extent that any person or entity has already acted in reliance on my
authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal
right to contest a claim.

5. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned
on whether I sign this authorization.

6. I understand that information used or disclosed pursuant to this authorization may be disclosed by
the recipient and may no longer be protected by federal or state law.

Participant or Personal Representative Name: 

Text field

Relationship to
Participant:

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Participant Signature:

Signature

Date: Date

 

Tribe Recovery Homes LLC. Financial Agreement 

Participant Name: Text field

Location: Text field

Admission Date: Date

Social Security Number: Text field

I, Text field , Understand that Tribe Recovery Homes LLC. Program fees are a one-time NON-REFUNDABLE ADMINISTRATION FEE OF $250.00 DUE PRIOR TO THE DAY OF ADMISSION. And $800.00 for a single space in a shared unit per month Plus a $15.00 Supply Fee Every Month. With the following payment options: 


Bi-Weekly $407.50: 

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Bi-Weekly payments are due on the 1 st & 14 th or late fee applies 

Bi-Weekly may only be utilized for the first 90 days 

Monthly $815.00:

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DOC/ Re-entry may be utilized for a maximum of 60 days 

Monthly Payments Are Expected to Be Paid by the 1 st Of Each Month at midnight on the 1 st late fee applies

I, Text field, Understand I am required to pay the fees on agreed payment schedule dates, and in case of any late payment there will be a $50.00 late fee applied to my ledger (Max of One fee per month). And if no payment is made at 72 hours past due, Tribe Recovery Homes LLC. reserves the right to enforce instant eviction from house! 

I, Text field, Understand that random drug/alcohol screening is apart of Tribe Recovery Homes LLC. program requirements and if I ever refuse to comply, I will be asked to leave immediately. 

I, Text field, Understand that Tribe Recovery Homes LLC. Does Not Issue Any Refunds, And I also understand if I vacate prior to end of month there are no reimbursements for any time left I did not stay. If I decide to return to Tribe Recovery Homes I will be required to pay the full move in costs. 

Checkboxes I Understand because of any relapse I will be given an option to be transported to a detox center of my choosing 

Checkboxes I may be asked to leave due to violating ANY of Tribe Recovery Homes LLC. Rules at anytime 

Checkboxes  If I leave without submitting a written 14-day notice to Tribe Recovery Homes LLC. I Understand I will be CHARGED an ADDITIONAL $250.00 WITHOUT NOTICE FEE 

This agreement also informs if there is an instant relapse eviction, or any other non-mutual separation where any staff of Tribe Recovery Homes LLC. feels it is unsafe for you to collect your belongings at time of eviction Tribe Recovery Homes LLC. will hold your belongings for 72 Hours which if not retrieved your belongings will be considered forfeited and donated. 

Participant Signature:

Signature

Date: Date

Staff Signature:

Signature

Date: Date 

Witness Signature:

Signature

Date: Date