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 gender

Treatment center 1 started

Veteran: Client veteran status

______________________________________________________________________________________________________________________________

Treatment Experience

 

Are you currently in treatment?

If yes, where? TreatmentCenterHistory

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

 

_____________________________________________________________________________________________

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: Date

Please tell us about your recovery history (including past successes and obstacles to maintaining 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: 

Checkboxes

If so, what are you allergic to? Client allergies

 

__________________________________________________________________________________________________________________________

 

Employment & Education

Are you employed? 

Checkboxes

If yes, who is your employer? Text field

If not, what job plans do you have? Text field

What is your monthly income right now? Employment 1 income

Are you in School: 

Checkboxes

Highest level of education completed: Dropdown

__________________________________________________________________________________________________________________________
  

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? 

Checkboxes

If Yes, what are you convicted of? Text field

 

Have you ever been convicted of a felony? 

Checkboxes

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, Text field

Name:Text field

Telephone Number:Text field

 

Do you have a mental health counselor? Checkboxes

If yes, Text field

Name:Text field

Telephone Number: Text field

 

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

Psychosis NOS

Checkboxes

Obsessive-Compulsive Disorder (OCD)

Checkboxes

Alcohol abuse

Checkboxes

Anger

Checkboxes

Substance abuse

Checkboxes

Suicide attempt

Checkboxes

Interpersonal Violence

Checkboxes

Eating Disorder

Checkboxes

 

COVID 19

In order to move into a Shoreline recovery residence you must be vaccinated and boosted or willing to get vaccinated within one day of moving in.

Have you been vaccinated against COVID? Checkboxes

If yes, what are the dates of your vaccinations Date  Date What are the dates of Boosters received? Date  Date

If you haven't received the booster, you will be required to do so to live at Shoreline.

Statement of Perjury

It is important that the information you give us is true and that you understand what happens if you are not giving truthful information on this form. You may be punished by fine or imprisonment or both (18 U.S.C. 1001). To indicate you have read and understand the above, please certify below:

I, Text field, hereby certify that the answers I provided above are truthful. 

Text field (Signature) Date (Today’s date)

 ________________________________________________________________________________________________________________________________________________

 

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

Please contact Shoreline Recovery at 203.903.5523 after submitting this application to schedule an interview.