Tribe Recovery Homes Application

 

 If something doesnt apply to you, please answer with "NA"

 

Applicant Information:

Legal First Name: Client first name

Legal Middle Name: Client middle name

Legal Last Name: Client last name

Birthdate: Date Text field

Gender: Client gender

     If other, please explain: Text field

Race: Client race

Ethnicity: Client ethnicity

Phone Number: Client phone

Email: Client email

 

Are you going to have a vehicle at the home? Checkboxes

Valid Drivers License #: Text field

State Issued in: Text field

Insured Through: Text field

License Plate #:Text field

State issued in: Text field

 

Employment: (If none, please type "None")

Employer: Employer 1 name

Position: Employment 1 position

 

Insurance: (If none, please type "None")

Insurance provider: Dropdown

Group ID: Text field

 

Are you on any of the following Medically Assisted Treatments:

Methadone Checkboxes 

Suboxone Checkboxes

Sublocade Checkboxes

Vivtrol/Naloxone Checkboxes

Anabuse Checkboxes

Other Checkboxes

         Please explain:Text field

PLEASE NOTE we DO NOT accept any narcotic medications including but not limited to: Benzodiazapines, Barbituates, Narcotic pain medications, Amphetamines, etc.

 

Are you in need of any of the following:

Food Stamps Checkboxes

Healthcare Checkboxes

State Issued ID Checkboxes

Social Security Card Checkboxes

Birth Certificate Checkboxes

Bus Passes Checkboxes

 

 

 

Legal Situation: Dropdown

 Please explain: Paragraph

 

If yes, please provide County or Office of Supervision:

Text field

Officer name:

Text field

Officer Phone Number:

Text field

Officer Email Address:

Text field

 

What is your current financial situation?

Checkboxes

 

Who would be financially resposible for your Program Fees?

Dropdown

 

Is there anything else you would like to include?

Paragraph

 

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.

Tribe Recovery Homes performs a CBI Background Check on all potential applicants. This background check is to protect both current program participants and prospective applicants. 

By signing you give permission to Tribe Recovery Homes Inc to run a background check.

This background check does not disqualify you from the program eligibility, nor will the results be disclosed to ANY outside entities.

 

First Name: Client first name

Last Name: Client last name

Date: Date

Signature

 

                                                                Approved participant items upon intake:

 

                                                  Clothing                                                                         Personal Hygiene

                                                4 long-sleeved shirts                                                       1 Shampoo/conditioner
                                                4 short-sleeved shirts                                                      1 Razor
                                                2 dresses or skirts                                                            1 Body Wash
                                                2 pairs of shorts                                                               1 toothbrush/floss
                                                2 pairs of pants                                                                1 Loofah/rag
                                                1 dress outfit                                                                    1 Brush
                                                2 dresses                                                                           2 Towels
                                                2 pairs of pajamas                                                            Makeup
                                                5 pairs socks
                                                7 pairs of underwear
                                                2 bras
                                                2 pairs of shoes
                                                2 sandals
                                                1 pair of dress shoe