Shoreline Recovery Application

Shoreline Recovery Application

 

 

First Name: Client first name

Middle Name: Client middle name

Last Name: Client last name

Driver’s License (state & number): Text field

Email: Client email

Mobile Number: Client phone

Date of Birth: Client birthdate

Age: Text field

Marital status: Client marital status

Children: 

Checkboxes

If yes, how many and what are their ages? Text field

Gender: Client genderTreatment center 1 started

Veteran: Client veteran status

____________________________________________________________________________________________________________________________________

Treatment Experience

 

Are you currently in treatment?

If yes, where? Treatment center 1 name

Type of program:Treatment center 1 type

Clinician Name: Treatment center 1 notes

Clinician email address: Treatment center 1 address

Clinician telephone number: Treatment center 1 name

 

Admission date: Treatment center 1 started

Expected discharge date:Treatment center 1 ended

 

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Recovery 

 

Sobriety/Clean Date: Recovery history 1 sobriety date

List Alcohol & Drugs of Abuse: Client substances of choice

If admitted, what is your requested move-in date to a Shoreline Recovery home: Client admit date

Please tell us about your recovery history (to include past successes and obstacles to maintain sobriety):

Text field

 

Sober Living Experience

 

Have you ever lived in a sober house before?: 

Checkboxes

Name of Sober House: SoberLivingHistory

 ________________________________________________________________________________________________________________________________

 

Emergency Contact Information:

 

Contact #1

Name: Contact 1 name

Phone: Contact 1 phone

Contact 1 type

Email Address: Contact 1 email

 

Contact #2

Name: Contact 2 name

Phone: Contact 2 phone

Contact 2 type

Email Address: Contact 2 email

____________________________________________________________________________________________________________________________________

 

List of Current Medications: 

 

List Psychiatric Medications First

Medication #1 Medication 1 name

Medication #2 Medication 2 name

Medication #3 Medication 3 name

Medication #4 Medication 4 name

Medication #5 Medication 5 name

Medication #6 Medication 6 name

Other Medications: Medication 7 name

 

Allergies: 

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If so, what are you allergic to? Client allergies

 

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Employment & Education


Are you employed? 

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If yes, who is your employer? Text field

If no, what job plans do you have? Text field

What is your monthly income right now? Employment 1 income

Are you in School: 

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Highest level of education completed: Dropdown

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Legal

 

Do you currently have any pending legal cases?

Checkboxes

If Yes, what are you charged with? Text field

 

Are you currently on probation or parole? 

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If Yes, what are you convicted of? Text field

 

Have you ever been convicted of a felony? 

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If yes, what were you convicted of, and in what year did the conviction occur? Text field

 

Are you currently on the sex offender registry? 

Checkboxes

 

 ____________________________________________________________________________________________________________________________________

 

Medical & Psychiatric

 

Do you have a medical doctor? 

Checkboxes

If yes, Text field

Name: Text field

Telephone Number:Text field

 

Current medical conditions? 

Text field

 

Do you have a mental health medication prescriber? 

Checkboxes

If yes, 

Name:

Telephone Number:

 

Do you have a mental health counselor? 

If yes, 

Name:

Telephone Number:

 

Psychiatric History:

Have you been diagnosed with or treated for:

Bipolar disorder 

Checkboxes

 Depression 

Checkboxes

Post-traumatic stress 

Checkboxes

Anxiety 

Checkboxes

Schizophrenia 

Checkboxes

Schizoaffective 

Checkboxes

Alcohol abuse 

Checkboxes

Anger 

Checkboxes

Other substance abuse 

Checkboxes

Suicide 

Checkboxes

Violence 

Checkboxes

 

 ____________________________________________________________________________________________________________________________________

 

Medical Insurance

 

Insurance Provider: Client insurance provider

Group ID: Client insurance group ID

Policy Number: Client insurance policy #

Primary on Insurance: Client insurance other

 

Residential Fees

 

Who will be responsible for paying your residential fees and living expenses if you are accepted into Shoreline Recovery?

Name: Contact 3 name    

Relationship: Text field

Telephone: Contact 3 phone

Email Address: Contact 3 email

 

 

 

 

By continuing, you 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.

Resident Signature: Signature

Date: Date