Personal Information: 

This application should be filled out to the best of your ability. If you do not know the answer skip it and we can call you.

Date:Date 

Referred By:Client Referred By

Name:Client first nameClient last name

Date of Birth: DateGender: Client gender

Pregnant?Dropdown Dute Date:Date

Age:Text field Cell Phone:Client phone

Current Address:Client Address Do you have a valid ODL#Text field

Do you have valid insurance?Dropdown

Vehicle: (Year, Make, Model & License Plate) Text field

Sobriety Date:Date Date Last used:Date Length of use:Text field

Drug of Choice:Client substances of choice  

Will your UA be clean if voted in?Checkboxes 

If no, what will your UA be positive for? Text field 

Are you attending any recovery based meetings?Text field

Are you enrolled in any Programs in the community? Checkboxes Program Support Person Name and contact: Text field

(Any names and contact information provdied with be considered a Release of Information consent)

List any prior Treatment, Sober Living, Detox or Mental Health Counseling and start and end dates of services:Text field  

List all RX/OTC Medication (pill count is not necessary):Text field

Reason for Medication:Text field

Medical & Mental Health Conditions/Diagnosis:Client diagnosis

Do you have Oregon Health Plan (OHP):Yes: Checkboxes OHP Number: Text field

Have you ever lived at Soaring Heights?Checkboxes

When and why did you leave? Text field

Employment or Prior Education:

School/former School: Client school  

Are you enrolled in any school or trade program:Checkboxes What school or Trade Program:Text field

if not, are you ready to work?Text field

Employer:Text field Employed for how long:Text field

Monthly Income:Text field

Family Information:

Marital Status:Client marital statusText field

How many children do you have:Text field 

Children who live with you names and birthdates: Text field 

Who do your children live with and is there a custody agreement in place?:Text field

Do you have a DHS/CPS Caseworker? :Checkboxes Name: Text field Contact Number: Text field

(Any names and contact informatoin provided will be considered a Release of Information consent)

Emergency Contact:

Name:Contact 

Legal Information:

Arrests:Criminal History Drug related?:Dropdown Alcohol related:Dropdown

Probation or Parole Officer name :Text field Phone number: Text field

Have you ever registered as a sex offender?Checkboxes When: Date

Have you ever been convicted of a violent crime?Checkboxes Date of Conviction: Date Date Date

Is there a no-contact or restraining order against you or against someone else?:Checkboxes Date put in place:Date Date it Expires: Date

If so with who:Text field

Do you have current Charges: Checkboxes List Charges : Text field

Past Convictions:Checkboxes List Convictions and dates: Text field

Will you need to appear in court while living at Soaring Heights Recovery Homes?: Checkboxes List your court dates: Date Date Date

Are you interested in expungement clinics?:Checkboxes

I certify that the facts set forth in this application are true and complete, to the best of my knowledge. This form will act as your first Release of Information allowing us to make contact with any support program or person you are working with. By signing you understand that attempts to contact will be made. Information will only be gathered regarding their support program. 

SignatureDate

Witness (if applicable):SignatureDate

For staff use only:

House Name:Client facility

Voted in?:Text field