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

Veteran: Client veteran status

______________________________________________________________________________________________________________

Treatment Experience

 

Are you currently in treatment? 

Checkboxes

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: RecoveryHistory

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):

Paragraph

 

Sober Living Experience

Have you ever lived in a sober house before?: 

Checkboxes

Name of Sober House: SoberLivingHistory

When did you live there and for how long? Text field

 __________________________________________________________________________________________________________________________

 

Emergency Contact Information:

 

Contact #1 Name, Phone, Email

Contact

 

Contact #2 Name, Phone, Email

Contact

 

_____________________________________________________________________________________________________________

 

List of Current Medications: 

List Psychiatric Medications First

Medication

 

Allergies: 

Checkboxes

If so, what are you allergic to? Client allergies

 

__________________________________________________________________________________________________________________________

 

Employment & Education

Are you employed? 

Checkboxes

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

Employer name and income:

EmploymentHistory

Are you in School: 

Checkboxes

 

Highest level of education completed: EducationHistory

__________________________________________________________________________________________________________________________
  

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

Probation

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

 Therapist/Clinician

Telephone Number:Text field

 

Current medical conditions? Client health problems

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:

Client diagnosis

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

 __________________________________________________________________________________________________________________________

 

Medical Insurance

 

Insurance Provider: Insurances

 

 

Residential Fees

 

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

Name: Contact   

 

Full payment is required in advance to confirm your stay at Shoreline. Please Initial Initials Text field

Shoreline Recovery monthly guest fees are either $800 or $1200 per month depending on single or double occupancy.  Contact Karen directly at karen@shorelinerecovery.org or 203.605.7543 if you are unsure what your specific fee amount is.

We offer several ways to make payment:

Zelle - karen@shorelinerecovery.org
Venmo - @Karen-Ablondi
Cash App - $KarenAblondi
Credit Card - A 3% service charge is applied.

At Shoreline Recovery, we honor the right of first refusal. In doing so, you will be notified if someone else is looking to move in before you. If you want to guarantee the bed for yourself or a loved one, your financial responsibility will start on that day.  If you decline this right, you will be notified when another bed becomes available. Please Initial  Initials Text field

Shoreline Recovery Cancellation & Refund Policy:

1. Payments made will be refunded in full (less a $50 processing fee) if you cancel 14 days or more before your arrival date. Please Initial Initials Text field

2. If you cancel between 13 days and 1 day in advance, a nonrefundable credit (less a $100 processing fee) will be held for one year from the date of issue. Please Initial Initials Text field

3. No credit or refund is available if you cancel on your arrival day or if you do not show up, or if you leave Shoreline after moving in for any reason. Please Initial Initials Initials Text field

4. The monthly guest fee ($800-$1200) is due on the 1st of each month. Please Initial Initials Text field

5. The move-in fee ($400) is not a deposit. It is non-refundable. Please Initial Initials Text field 

6. Guests are responsible for their food and are required to pay monthly house dues ($20). Please Initial Initials Text field

 

 

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.