Our living environment provides our residents with adequate structure and accountability with enough freedom to manage their own lives, while complying with the expectations of the FreedomWorks Recovery Community.
FreedomWorks staff will review the application and promptly send you a letter with our decision within two weeks.
Date of Application: Date Desired move-in date: Date
Resident first name:Client first name Resident middle name: Client middle name Resident last name: Client last name
Social Security#: Text field Date of Birth: Date Phone: Client phone
Email: Client email
Marital status: Dropdown Number of children: Text field Child support? Dropdown
Street: Text field apt #: Text field City: Text field Zip Code: Text field
Do you own your own vehicle? Dropdown
Year: Text field Make: Text field Model: Text field License Plate Number: Text field
Do you have a valid drivers license? Dropdown
State: Text field License number: Text field
Are you leaving another program? Dropdown
If yes, where?Text field Who referred you to us? Text field
What is your main interest in FreedomWorks? (Click all that apply)
Have you ever been incarcerated? Dropdown
How long? Text field Reason: Text field
Are you currently on..... (Check all that apply)
Have you ever been convicted of a sexual offense? Dropdown
Do you have to register for any offenses? Dropdown
Do you have any current or pending charges? Dropdown
If yes, please explain Paragraph
Mental Health Diagnosis if any? Text field
Are handicap or living accomodations necessary? Dropdown Please list Accomodations Needed: Text fieldPlease list any medication you are taking :
Checkboxes Text field
Drug of Choice: Text field
Do you have a sponsor? Dropdown
(If yes, fill out the Contact portion below for your sponsor).
Are you employed? Dropdown Employer (if yes): Text field
Job title: Text field Monthly Income: Text field
Do you have any other income (SSI, SSDI, Unemployment, etc.) Dropdown If yes, what is the monthly income? Text field
I currently have:
Have you ever received GA/GRH? Dropdown
Please submit 1 Emergency contact, 2 References and your Sponsors information.
AuthorizationsBy 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.
I authorize FreedomWorks staff to contact my counselors, caseworker, parole offices, and any other supportive team member for additional information if needed.
Signature Date: Date
Applicant's Full name: Client first name Middle name: Client middle name Last name:Client last name
Date of Birth: Date SSN: Text field
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 Sober Housing Recovery Community. I also authorize FreedomWorks staff to review and/or to receive mental health, physical health and probation/parole records upon request. 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 action has been taken in reliance on it.Communications resulting from this authorization will reveal that I have received or have attempted to receive accommodations at FreedomWorks’ Sober Housing Recovery Community.Federal confidentiality regulations prohibit disclosure of information.While living in the FreedomWorks Sober Housing Recovery Community. I cannot revoke the authorization release of information. I can, however, revoke this authorization upon leaving FreedomWorks.
Office use only:FreedomWorks Staff signature:______________________ Date:______________________________________________________________________________________________________________________________________________I chose to revoke this authorizationParticipant signature: ____________________________ Date: ____________