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#: 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
Street: Client Address apt #: Text field City: Client City State:Client State Zip Code: Client Zip
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)
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? 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 :
Checkboxes Text field
Drug of Choice: Client substances of choice
Do you have a sponsor? Dropdown
(If yes, fill out the Contact portion below for your sponsor).
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
Please submit 1 Emergency contact, 2 References and your Sponsors information.
AuthorizationsBy 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.
Signature Date: Date
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.
Office use only:FreedomWorks Staff signature:______________________ Date:______________________________________________________________________________________________________________________________________________I chose to revoke this authorizationParticipant signature: ____________________________ Date: ____________