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:

                         Desired program start date:                   

Date of last use:   

                         Who referred you to us? 

Personal Information

First name:

     Middle name:    Last name: 

Date of Birth: 

          Phone:        OID:                   

Gender:

                     Ethnicity:    

Email:  

                                 Marital status:              

Number of children:

     Child support?   

Address

Street: 

                apt #:            City:         

State:

       Zip Code:    

Vehicle

Do you have a valid driver's license?

   State:    

Driver's License number:

  Information given WILL be verified.

Please fill out the below if you own a vehicle:

Year: 

     Make:            Model:          

License Plate Number: 

    State Issued: 

   

Which FreedomWorks program are you applying for?

Criminal History

Have you ever been incarcerated? 

   

How long?

     Charge: 

Are you currently or will you be on?

Have you ever been convicted of a sexual offense?

   

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

Do you have any pending charges?

 

If yes, please explain 

Medical History

Mental Health Diagnosis if any?   

     

Please list current Health Conditions: 

Are ADA accommodations necessary? 

   

Please list Accommodations Needed: 

Please list any allergies:

Please list any medication you are taking : 

Your Recovery

Addiction type(s): 

Drug of Choice: 

Do you have a sponsor? 

     

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

 

Past Treatment:

Employment

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

 

If yes, what is the monthly payment? 

 

Have you ever received GA/GRH?

                 If so, date last on it? 

Contact: 

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

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:

 Date:

 

Release of Information Authorization                   

I (print 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:

 Date:

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