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#: Text field            Date of Birth: Date                                Phone:  Client phone                                   

Email:  Client email                                       

Marital status:    Dropdown              Number of children: Text field                       Child support? Dropdown  

Address

Street: Text field                apt #:  Text field           City:    Text field                           Zip Code: Text field

Vehicle

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

Reference

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)

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?   Text field     

Are handicap or living accomodations necessary? Dropdown   Please list Accomodations Needed: Text field
Please list any medication you are taking : 

Paragraph

 

Your Recovery

Addiction type(s): 

Checkboxes Text field

RecoveryHistory

Drug of Choice: Text field

Do you have a sponsor? Dropdown     

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

 

Past Treatment:

TreatmentCenterHistory

 

Employment

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: 

Checkboxes

Have you ever received GA/GRH? Dropdown

 
Contact: 

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

Contact

  

Authorizations
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.

I authorize FreedomWorks staff to contact my counselors, caseworker, parole offices, and any other supportive team member for additional information if needed.

Applicant Signature:

Signature  Date: Date

 

Release of Information Authorization


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.

Applicant Signature:

Signature  Date: Date

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