Freedomworks Quick Application

Resident Housing Application


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                

Personal Information


Resident first name:Client first name     Resident middle name: Client middle name    Resident last name: Client last name

Social Security#: SSN            Date of Birth: Client birthdate                                Phone:  Client phone                                   

Email:  Client email                                                                    Who referred you to us?  Text field

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 drivers license? Dropdown   State: Text field    Driver's License number: Text field

Please fill out the below if you own a vehicle:

Year:  Text field     Make:  Text field           Model: Text field         License Plate Number: Text field

   

What is your main interest in FreedomWorks? (Click all that apply)

Checkboxes

Criminal History


Have you ever been incarcerated?  Dropdown   

How long? Text field     Reason: Text field

Are you currently on..... (Check all that apply)

Checkboxes

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

Medical History

Mental Health Diagnosis if any?   Client diagnosis     

Please list current Health Conditions: Client health problems

Are handicap or living accomodations necessary? Dropdown   Please list Accomodations 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 income (SSI, SSDI, Unemployment, etc.) Dropdown  If yes, what is the monthly income? 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

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: ____________