Participant Lodging Application

Our  Recovery Community provides our participants with adequate structure and accountability with enough freedom to manage their own lives while complying with the expectations of the FreedomWorks Recovery Community program.

FreedomWorks staff will review the application and schedule a time for a phone interview.

  

Date of Application: Date                         Desired program start date: Date                  

Date of last use:   Date                         Who referred you to us? Text field

Personal Information

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

Date of Birth: Client birthdate          Phone:  Client phone      OID: Text field                  

Gender:Client gender                     Ethnicity: Client race   

Email:  Client email                                 Marital status:    Client marital status          

Number of children: Text field     Child support? Dropdown  

Address

Street: Client Address                apt #:  Text field          City:    Client City     

State:Client State       Zip Code: Client Zip   

Vehicle

Do you have a valid driver's license? Dropdown   State: Client State    

Driver's License number: Text field  Information given WILL be verified.

Please fill out the below if you own a vehicle:

Year:  Text field     Make:  Text field           Model: Text field         

License Plate Number: Text field    State Issued: Text field

   

Which FreedomWorks program are you applying for?

Checkboxes

Criminal History

Have you ever been incarcerated?  Dropdown   

How long? Text field     Charge: Text field

Are you currently or will you be on?

Checkboxes

Have you ever been convicted of a sexual offense? Dropdown   

Are or will you be required to register as a predatory or violent offender?   Dropdown

Do you have any pending charges? Dropdown  

If yes, please explain Paragraph

Medical History

Mental Health Diagnosis if any?   Client diagnosis     

Please list current Health Conditions: Client health problems

Are ADA accommodations necessary? Dropdown   

Please list Accommodations Needed: Text field

Please list any allergies: Client allergies

Please list any medication you are taking : 

Medication

Your Recovery

Addiction type(s): 

Checkboxes Text field

RecoveryHistory

Drug of Choice: Client substances of choice

Do you have a sponsor? Dropdown     

(If yes, fill out the Contact portion below for your sponsor).

 

Past Treatment:

TreatmentCenterHistory

Employment

EmploymentHistory

Do you have any other UNearned income (SSI, SSDI, Unemployment, etc.) Checkboxes 

If yes, what is the monthly payment? Text field

 

Have you ever received GA/GRH? Dropdown                 If so, date last on it? Date

Contact: 

Please submit 1 Emergency contact, 2 References and your Sponsors information. 

Contact

Contact

Authorizations
By signing, you agree to the validity of the information on this form. You also 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.

 

Applicant Signature:

Signature  Date: Date

 

Release of Information Authorization                   

I (print name)Client first nameClient middle nameClient last name authorize FreedomWorks staff the right to speak to individuals, referrals and/or agencies regarding my acceptance into FreedomWorks and to review and/or to receive mental health, physical health and probation/parole records upon request.  These individuals include my counselors, caseworker, parole offices, and any other supportive team members for additional information as needed.  I understand that:

My health information is protected by Federal Confidentially Rules (42 CFR Part 2; and/or HIPAA, 45 CFR) and state privacy laws, and disclosure is allowed only with my authorization except in limited circumstances as outlined in FreedomWorks policies. I also understand that I have the right to inspect and receive a copy of my treatment records that may be disclosed to others as provided under applicable state and federal laws.
I can revoke this authorization in writing at any time by providing a written notification to FreedomWorks, except to the extent that the FreedomWorks programs rely upon it.   I can revoke all authorization upon leaving FreedomWorks. Communications resulting from this authorization will reveal that I have received or have attempted to receive accommodations at the FreedomWorks Campus.  Federal confidentiality regulations prohibit disclosure of information.
  

Applicant Signature:

Signature  Date: Date

Office use only:
FreedomWorks Staff signature:______________________ Date:_____________
_________________________________________________________________________________________________________________________________
I chose to revoke this authorization
Participant signature: ____________________________ Date: ____________