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
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
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 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?
Have you ever been incarcerated? Dropdown
How long? Text field Charge: Text field
Are you currently or will you be on?
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
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: ____________