Intake Application 

      *ALL QUESTIONS MUST BE ANSWERED TO THE BEST OF YOUR ABILITY*

 

Please select the facility you are interested in:

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Date of Referral: Date Referred By: Client Referred By Phone #: Text field Email: Text field

How did you hear about Recovery Point: Text field

Have you been a resident here before? Radio buttons If yes, when? Text field

Have you ever been convicted of a violent crime? Radio buttons

Are you required to register as a sex offender? Radio buttons

Are you pregnant?Radio buttons

Are you currently on any MAT (example: Suboxone, Methadone, etc.) Radio buttons

If you answered yes, please list which medication: Text field

 

Resident Information             Social Security Number: SSN

Last Name: Client last name First Name: Client first name Middle Name: Client middle name

 Current Residence/or Last Known Residence(Non-Facility): Client AddressClient CityClient StateClient Zip

Phone #: Client phone DOB: Client birthdate

Marital Status: Client marital status

Race: Client race

Ethnicity: Client ethnicity

Gender: Client gender

Homeless? Radio buttons

 

Substance Use History (Past 12 months)

Alcohol - Date of last use: Date Frequency of use: Text field Avg. amount used (daily): Text field

Cocaine - Date of last use: Date Frequency of use: Text field Avg. amount used (daily): Text field

Heroin - Date of last use: Date Frequency of use: Text field Avg. amount used (daily): Text field

Other Opiates - Date of last use: Date Frequency of use: Text field Avg. amount used (daily): Text field

Marijuana - Date of last use: Date Frequency of use: Text field Avg. amount used (daily): Text field

Methamphetamine - Date of last use: Date Frequency of use: Text field Avg. amount used (daily): Text field

Benzodiazepines - Date of last use: Date Frequency of use: Text field Avg. amount used (daily): Text field

Hallucinogens - Date of last use: Date Frequency of use: Text field Avg. amount used (daily): Text field

Synthetic - Date of last use: Date Frequency of use: Text field Avg. amount used (daily): Text field

Suboxone - Date of last use: Date Frequency of use: Text field Avg. amount used (daily): Text field

 

Are you able to walk 5 miles/day and stand on your feet for 30 hours per week? Radio buttons

Do you need assistance with activities of daily living (bathing, feeding, dressing, etc)? Radio buttons

 

Current Medical Issues 

 Radio buttons

Developmental disability? Text field

HIV/AIDS? Radio buttons Hep A/B/C? Radio buttons Chronic Health Condition? Radio buttons

Are you a domestic violence victim? Radio buttons

Are you currently fleeing a violent situation? Radio buttons Protective Order? Radio buttons

Physical Disability? Radio buttons

Current Mental Health/Emotional Issues (Depression, Anxiety, etc)

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Past diagnosis? Radio buttons Past psychiatric hospitalizations? Radio buttons

Are you experiencing a mental health crisis today? Radio buttons (Hearing Voices, thinking of hurting self or others?)  Radio buttons

 

As a client of Recovery Point West Virginia, you will be required to have a mental health assessment b a licensed behavioral health center or other behavioral health proivders, and you will be required to comply with the professional treatment recommendations that result from that mental health assessment. Do you agree to this requirement as part of the terms of your eligibility for the RPWV peer to peer program? By answering yes, you acknowledge that you may be discharged from the program if you fail to follow the instructions of your health providers, including any mental health or behavioral provider. 

Radio buttons

Medications 

Medication

 

 

Justice System Involvement:           

Are you a convicted felon? Radio buttons

Are you required by the courts or any other legal entity to enter this program? Radio buttons

If so, what County? Text field Who is the Judge? Text field

Probation or parole? Radio buttons PO’s Name Text field Phone Text field PO's Email: Text field

Are you Out on Bond? Radio buttons Court in the next week? Radio buttons

Current criminal charges?

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Active warrant? Radio buttons

Your lawyer’s name Text field Phone Text field Lawyers Email Text field

Supplemental Information we may need to know?

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DHHR and CPS Information:

How many children do you have? Text field

CPS Worker Name: Text field

Do you have a CPS case? Text field CPS Worker phone: Text field County: Text field

CPS Lawyer name: Text field CPS lawyer number: Text field

 

 

 

Resident Signature Signature Date Date

Staff Signature Signature Date Date

**Failure to disclose justice system involvement or any information contained in this application, can result in immediate discharge. By

signing this document, you are confirming that all information is complete and correct.