One Step

Intake Form

F.I.R.S.T. Recovery Home

For Individuals Recovering Sound Thinking
9 Bird St, Dorchester, MA 02125
Stephenie Jackson, Owner 617-506-8861 business Tel. 617-407-7879 cell 857-271-3946 fax

Name: Client first name Client middle name Client last name
Previous Address: Client Address City: Client City State: Client State Zip: Client Zip
Telephone: Main phone: Client phone Work Text field Home: Text field
Date of birth: Client birthdate Sex:Client gender Social Security No.Text field
Are you currently homeless/without a permanent place to live?

Radio buttons
Marital Status: Client marital status

Health Insurance number:

Provider: Client insurance provider Insurance Plan: Client insurance plan

Group ID: Client insurance group ID Policy#: Client insurance policy #

Therapist: name: Contact 1 name Phone: Contact 1 phone

Psychiatrist:name: Contact 2 name Phone: Contact 2 phone

Physician:Name: Contact 3 name Phone: Contact 3 phone

Medical Condition:Client diagnosis
Are you taking any prescription medications?

Radio buttons

If yes, please list them:

Medication 1: Medication 1 name Dosage: Medication 1 dosage

Quantity: Medication 1 quantity Category: Medication 1 category

Frequency: Medication 1 frequency MD: Medication 1 md

Pill count: Medication 1 pill count Discontinued at: Medication 1 discontinued at

Notes: Medication 1 notes

Medication 2: Medication 2 name Dosage: Medication 2 dosage

Quantity: Medication 2 quantity Category: Medication 2 category

Frequency: Medication 2 frequency MD: Medication 2 md

Pill count: Medication 2 pill count Discontinued at: Medication 2 discontinued at

Notes: Medication 2 notes

Medication 3: Medication 3 name Dosage: Medication 3 dosage

Quantity: Medication 3 quantity Category: Medication 3 category

Frequency: Medication 3 frequency MD: Medication 3 md

Pill count: Medication 3 pill count Discontinued at: Medication 3 discontinued at

Notes: Medication 3 notes

Medication 4: Medication 4 name Dosage: Medication 4 dosage

Quantity: Medication 4 quantity Category: Medication 4 category

Frequency: Medication 4 frequency MD: Medication 4 md

Pill count: Medication 4 pill count Discontinued at: Medication 4 discontinued at

Notes: Medication 4 notes

Drug of choice:Client substances of choice

Have you been to rehab?

Radio buttons

If Yes, where?

Center name 1: Treatment center 1 name

Address: Treatment center 1 address

City: Treatment center 1 city State: Treatment center 1 state Zip: Treatment center 1 zip

Admitted: Treatment center 1 started Discharged: Treatment center 1 ended

Notes: Treatment center 1 notes

Type: Treatment center 1 type

Reason for discharge: Treatment center 1 reason for discharge

Center Name 2: Treatment center 2 name

Address: Treatment center 2 address

City: Treatment center 2 city State: Treatment center 2 state Zip: Treatment center 2 zip

Admitted: Treatment center 2 started Discharged: Treatment center 2 ended

Notes: Treatment center 2 notes

Type: Treatment center 2 type

Reason for discharge: Treatment center 2 reason for discharge

Date of last TB test: Date

Are you a recovering: Alcoholic? Checkboxes Drug addict?Checkboxes

Sobriety/Recovery date:Recovery history 1 sobriety date

Do you attend AA or N/A meetings?

Radio buttons

Employer:

mployer: Employer 1 name Position: Employment 1 position

Started: Employment 1 started Ended: Employment 1 ended

Income: Employment 1 income

Type: Employment 1 type

Notes: Employment 1 notes

Do you have any outstanding warrants?

Radio buttons

Do you have any sex offenses?

Radio buttons

Referral source: (If coming from an institution, which one?):

Client referral source

Release/Discharge Date: Text field

List name of parole or probation officer: Text field

List names and telephone numbers of two individuals who may be contacted in the event of an emergency:

Name: Contact 4 name Phone: Contact 4 phone

Type: Contact 4 type Email: Contact 4 email

Name: Contact 5 name Phone: Contact 5 phone

Type: Contact 5 type Email: Contact 5 email

F.I.R.S.T. Recovery Home is a sober environment and cannot tolerate program members using alcohol/drugs. If a member is found
to be using either substance he will be immediately discharged for illegal activity. It is understood by the FIRST members that use
of alcohol or drugs is a violation of their membership because it is either unlawful or in violation of terms of their probation or
others released to this recovery home.

Signature:

Signature

Date:

Date

F.I.R.S.T. Recovery Home
For Individuals Recovering Sound Thinking
9 Bird St, Dorchester, MA 02125
Stephenie Jackson, Owner 617-506-8861 business Tel. 617-407-7879 cell
857-271-3946 fax

F.I.R.S.T. Recovery Home is a sober environment that provides stabilization and a supportive sober
atmosphere.

1. Members must be sober and actively maintaining sobriety by being involved in a recovery
program.

2. Members must have the ability to pay $150.00 weekly rent.

3. A $250 security deposit is required

4. Residents of the community house must have a willingness to cooperate with other persons
living here and contribute to improving the house and community.

5. Members are expected to abstain from alcohol and other substances. If using alcohol/drugs or
involved in any drug activity, member will be immediately placed in a detox. Upon completion
of a seven day detox the resident can return to the house. In addition, every resident will be
screened a minimum of 1-2 times per week. If it is suspected a resident is not sober the house
may give a random drug screen.

6. Sexual contact between residents is cause for immediate discharge.

7. Non-payment of your rent is subject to disciplinary action and may result in discharge. The
rent is due by Wednesday of each week prior to leaving the House for the weekend.

8. Disruptive, threatening or abusive behavior to any member and/or staff will not be tolerated
and is grounds for discharge.

9. Members must agree to participate in at least one N/A or AA meetings per week.

10. Members must agree to participate in a minimum of (1) urine screen per weeek.

11. Members must attend one 1 in-house meeting upon request when necessary.

12. All residents living at F.I.R.S.T. must be in the house by: 11:00 pm. Sunday through Thursday;
weekends (Friday & Saturday) by 1:00 am.

13. Members will not be permitted to have overnights for one week. Overnights are Friday and
Saturday.

14. Members must be willing to do assigned chores.

MY SIGNATURE INDICATES THAT I HAVE READ AND UNDERSTAND ALL OF THE AFOREMENTIONED,
AND IF I AM ACCEPTED, I AGREE TO ABIDE BY ALL OF THE RULES AND RESPONSIBILITIES OF THE
SOBER HOUSE RULES AND THAT I AM AWARE OF DISCIPLINARY ACTION WHICH COULD RESULT IN
IMMEDIATE DISCHARGE.

Signature:

Signature

Date:

Date

Consent Form

I Client first name Client last name an applicant for F.I.R.S.T. Recovery Home hereby
voluntarily consent to requests for urines and/or saliva specimen and agree to fully participate in
the weekly testing.
If my specimen is found to be positive, I understand I will be immediately discharged from
F.I.R.S.T. Recovery Home.
Signature:

Signature

Date:

Date

I Client first name Client last name have read the aforementioned consent information, rules,
criteria and application provided by F.I.R.S.T., Recovery Home. I understand that if I am accepted
I agree to the following terms.

Signature:

Signature

Date:

Date

CONDITIONS

1. N/A and A/A slips must be signed whenever attending meetings. They will be
checked every week by the Manager.

2. Urines are scheduled at least once per week.

3. HOUSE MEETING: Time schedule is determined by the Program Manager.

4. Curfew is in effect at all houses. Specifically: Sunday through
Thursday at 11:00 p.m, Friday and Saturday at 1:00 a.m.

5. No cooking after 10 p.m.

6. All belongings must be picked up 14 days after a resident leaves the house.
If belongings are not picked up during this period, they will be donated.
FIRST RECOVERY HOME is not responsible or any belongings lost or stolen.

7. Smoking is done outside the house. Smoking in the house will result in
discharge.

8. No loitering in front of the Buildings.

9. All rooms should be neat and cleaned every day.

10. Visitors are allowed only on Saturdays and Sundays from 12pm till 8pm.
No Exceptions to the rules.

PLEASE KEEP THIS FORM.

Signature:

Signature

Date:

Date