Freedomworks Quick Application

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? Dropdown

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                         Gender:Client gender                     

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 drivers license? Dropdown   State: Text field    

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 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: ____________