Ryse Recovery Application
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General
Tell us about yourself
What is your first name?
Client first name
What is your middle name? No middle name? Move on to the next question.
Client middle name
What is your last name?
Client last name
When is your birthdate?
Client birthdate
What is your race/ethnicity?
Client race
What is your gender?
Client gender
What is your marital status?
Client marital status
Are you a veteran?
Client veteran status
Questions
Program Cost:
Woodbridge Locations: $225/week
$600 Move in fee
$225 First Week's Rent
$225 Second Week's Rent
$150 Non- Refundable Admin Fee
Princeton Area Locations: $250/week
$650 Move in fee
$250 First Week's Rent
$250 Second Week's Rent
$150 Non- Refundable Admin Fee
How will you pay for the program? (You can select one or multiple options)
Checkboxes
If someone else, who will be paying?
Checkboxes
Are you set up with aftercare? (IOP, OP, Therapy)
Radio buttons
Do you need assistance/referral for a program?
Radio buttons
Do you have any concerns with sharing a room?
Radio buttons
Are you able to perform household chores?
Radio buttons
Contact Information
How can we reach you?
What is your email address?
Client email
At what phone number can we best reach you at?
Client phone
Street Address:
Client Address
City:
Client City
State:
Client State
Zipcode:
Client ZipConsent to contactI consent to be contacted by Ryse Recovery via SMS, email, or phone using the information I provided for the purposes of reviewing my application.
Contacts
Give us a few people that we can reach out to in case of an emergency.
Contact
Insurance
Enter your insurance provider(s).
Insurance
Medical History
Tell us about your medical history.
When was your last relapse date?
Recovery history 1 relapse date
What is your substance(s) of choice? Add multiple by clicking in the box and selecting different options
Client substances of choice
Have you been clinically diagnosed with anything? Add multiple by clicking in the box and selecting different options
Client diagnosis
Do you have any health problems? Add multiple by clicking in the box and selecting different options
Client health problems
What kind of meetings do you attend? Add multiple by clicking in the box and selecting different options
Client kinds of meetings attended
What allergies do you have? No allergies? Move on to the next question.
Client allergies
How would you describe your current physical health?
Dropdown
Do you have a history of seizures?
Radio buttons
Do you have any physical health / medical conditions or disabilities?
Radio buttons
Do any of the following apply to you?
Checkboxes
Are you currently under the care of any of the following provider types:
Checkboxes
Do you have any medical equipment?
Checkboxes
Medications
List the medications you are currently prescribed.
Medication
Treatment Centers
Tell us about any treatment centers you've previously been admitted into.
TreatmentCenterHistory
Sober Living History
Tell us about any sober livings you've previously been admitted into.
SoberLivingHistory
Employment
Tell us about your employment status.
If you're currently unemployed select "unemployed" under "type"
EmploymentHistory
Living Arrangement
Tell us about your living arrangement prior to moving into this facility
LivingArrangementHistory
Courts & Criminal Justice
Do you consent to a background check?
Radio buttons
Are you currently involved in any legal proceedings or criminal justice issues?
Radio buttons
Do you have a requirement for Community Service?
Radio buttons
Do you have any court ordered treatment requirements?
Radio buttons
Do you have any pending sentencing or possible jail time upcoming?
Radio buttons
Have you ever been charged or convicted of Arson?
Radio buttons
Have you ever been charged or convicted of a Felony?
Radio buttons
Have you ever been charged or convicted of any violent crimes in any jurisdiction?
Radio buttons
Have you ever been charged or convicted of any violent of abuse or neglect of any person, including but not limited to disabled persons, seniors, or children?
Radio buttons
Restrictions
Select all legal requirements that apply:
Checkboxes
Are you required to register as a sex offender?
Radio buttons
Are you required to register with any other authority for any other reason?
Radio buttons
Are there any restraining orders against you or by you?
Radio buttons
Admissions
When would you like to move in?
Date
Do you expect to move in on time?
Radio buttons
Do you have a personal relationship with anyone that works for Ryse Recovery?
Radio buttons
Have you previously applied to Ryse Recovery?
Radio buttons
How long would you hope to stay at Ryse Recovery?
Checkboxes
Are there any issues that could prevent you from completing the program?
Radio buttons
Client Statement
Why do you want to live in a sober home?
Paragraph
How did you hear about our program?
Text field
Were you referred to Ryse Recovery?
Client Referred By
What other information should we consider when reviewing your application?
Text field
Please describe what issues led you to seek housing with Ryse Recovery. Be specific as to details such as how, when, where and your personal responsibility.
Paragraph
What are your goals and expectations?
Paragraph
Why do you think you are a good fit for sober living?
Paragraph
What do you want to accomplish while residing at Ryse Recovery?
Paragraph