Roots, Recovery Communities

www.roots501.org

apply@roots501.org

985-445-8063 

Please fill out the below application to the best of your ability so we can see how Roots can best serve you.

Interview Application 

Client first name     Client middle name     Client last name     Client pronoun     Client nickname

Client email      Client phone     Client marital status     Client birthdate DOB  

SSNSSN     Admit Date  Client admit date     Discharge Date Client discharge date    Client Diagnosis Client diagnosis 

Which House Are You Applying For? 

Checkboxes           Checkboxes          Checkboxes

Contact Contact Information

Probation

Family Members

Medication

TreatmentCenterHistory

Currently Employed: yes/no Text field

Highest Level of Education: Text field

Recovery Housing History: Paragraph

RecoveryHistory

Client sponsor

Sobriety Date: Text field

Client estimated length of stay

Client health problems

Client substances of choice

Client kinds of meetings attended

Criminal History

Ever Convicted of sexual or violent crimes?: Text field

Outstanding Warrants?Text field

Currently awaiting charges, trial or sentencing: yes/no Text field 

Children (with custody): Text field

Children (without custody):Text field

Child Welfare History

History of Self-Harm: Text field

History of Mental Health Hospitalizations: Text field

History of Eating Disorder: Text field

Recent Suicidal ideation or Homicidal ideation:Text field

Relationship Status: Text field

Ability to Pay Rent: yes/no Text field

Food Stamps: yes/no Text field

Car: yes/no Text field

Driver's License/State ID: Text field

Birth Certificate: yes/no Text field

Social Security Card: yes/no Text field

What goals can we help you accomplish while living in Roots Recovery Community?

Paragraph

Signature

Date

By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.