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:
Text fieldEmergency 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:
If "other(s)", please specify:
3. Have you received help for drug or alcohol dependency? If yes, please specify when, for what and where:
4. How have you been coping with staying sober until now?
5. What support do you have in your life (Family / Sponsor / Recovery Coach / Friends / School / Work / Socialactivities, etc)?Paragraph
6. Which - if any - of these substances do you currently use or have used in the past? Please use the box to indicateyour age at first use and age at last use. (E.g.: Alcohol - 16, 30)
Checkboxes AlcoholText field
Checkboxes AmpheteminesText field
Checkboxes OpiatesText field
Checkboxes HeroinText field
Checkboxes MethamphetamineText field
Checkboxes BarbituratesText field
Checkboxes CaffeineText field
Checkboxes CocaineText field
Checkboxes Crack cocaineText field
Checkboxes Hallucinogens (e.g., LSD)Text field
Checkboxes Inhalants (e.g., glue, gas)Text field
Checkboxes Marijuana or hashishText fieldCheckboxes Nicotine/cigarettersText field
Checkboxes PCPText field
Checkboxes If "other(s)", please specifyText field
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:
If "other(s)", please specify
8. Have you received psychotherapy or counseling in the past? If yes, when was that? Please list the mental health careproviders (Counselor / Psychologist / Psychiatrist)' names and phone numbers:
9. If any, which have been the consequences of substance abuse in your life? Please use the box below to explain suchconsequences:
If "other(s)", please specifyText field
10. Describe your current physical health:Radio buttons
11. If you are currently under care of a Physician, please specify:
12. Which medications (psychotropic or not) are you currently taking?
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: 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
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
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
13. What is your current employment situation? Check all that apply:
If "other", please specify
14. If currently employed:What is your occupation?
Employer: Employer 1 name
Do you enjoy your work?
How many hours a day do you work?
Do you take work home with you?
15. How is your social interaction? Check all that apply:
If "other", please specifyText field
16. What is your current financial situation? Check all that apply:
CheckboxesIf "other", please specify:
17. What is your legal situation? Check all that apply:
Please Explain Each Answer CheckedParagraph
18. If you are on Parole or Probation, please provide the following:Location Of Parole/Probation:
ParagraphParole/Probation Officer Name:
Text fieldParole/Probation Officer Phone Number:
Text fieldParole/Probation Officer Email Address:
19. Please Provide Provide Insurance Information:
Insurance Type: (Medicaid, Medicare, Private Insurance):
Text fieldIf 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:
Watching TV / Video games:
Using the computer:
21. Relationship status:
Client marital status
If "other", please specify:
22. What are your passions and leisure pursuits?
23. What is your current level of stress?
24. How do you cope with stress?
25. What are the major causes of your stress? (Marital / Financial / Career / Family / Health / Unfulfilled expectations,etc)
26. Do you exercise? If yes, what type of exercise, how often and for how long, in average?
27. Drugs Used During Lifetime
28. How Long Have You Been Clean & Sober
29. Have You Ever Been On Any Form Of Medicated Assisted Treatments If So Check The Following Treatments You'veUsedCheckboxes
30. How Many Times Have You Been In Inpatient Treatment
31. How Many Sober Livings Have You Lived In
32. Why Did You Leave Your Last Sober Living
Paragraph33. After A Full Detoxification Period How Many Times Have You Relapsed
The Confidentiality of recovering persons living in a supportive living environment can be protected underFederal Law 42CFR, which protects residents from anyone outside of said program having knowledge oftheir participation in the program without the resident’s specific consent. No information regarding aresident 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 HomesLLC. or outside of the program, Also Federal Law does not restrict sharing of information regardingreported child abuse/neglect to appropriate state & local authorities. These Laws apply not only toresidents also the staff, board members and volunteers of Tribe Recovery Homes LLC.
I,Text field, Agree to not reveal to anyone outside of Tribe RecoveryHomes LLC. The name, identity or description of another resident. I also agree to not discuss the contentof conversations or groups with anyone outside of Tribe Recovery Homes LLC. This includes sharing atrecovery meetings. I agree to inform staff if any peers reveal any information about themselves or anotherresident 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 tomaintain 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 inpublic forums, whether electronically or otherwise.Any information made public will be grounds for immediate expulsion from the property and the program.
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:
Checkboxes - Text field
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, presentand future periods.
2. This medical information may be used by the person I authorize to receive this information formedical 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 timethis authorization expires.
4. I understand I have the right to revoke this authorization, in writing at any time. I understand that arevocation is not effective to the extent that any person or entity has already acted in reliance on myauthorization was obtained as a condition of obtaining insurance coverage and the insurer has a legalright to contest a claim.
5. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditionedon whether I sign this authorization.
6. I understand that information used or disclosed pursuant to this authorization may be disclosed bythe recipient and may no longer be protected by federal or state law.
Participant or Personal Representative Name:
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 payments are due on the 1 st & 14 th or late fee applies
Bi-Weekly may only be utilized for the first 90 days
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.