Fresh Wind Recovery Ministry Application
(Men and Women)
Thank you for considering Fresh Wind Recovery Ministry.
Click next to begin your application!
General
1. What is your first name?
Client first name
2. What is your middle name?
Client middle name
3. What is your last name?
Client last name
4. What do you prefer to be called?
Client nickname
5. When is your birthdate?
Client birthdate
6. What is your race/ethnicity?
Client race
7. What is your sex assigned at birth?
Checkboxes
8. What is your gender?
Client gender
9. What is your sexual orientation?
Checkboxes
10. What is your marital status?
Client marital status
11. Do you have any children?
Checkboxes
13. Are you pregnant?
Checkboxes
14. Do you have an active Child Protective Services case with DFCS?
Checkboxes
15. Do you have custody of your children?
Checkboxes
16. Are you seeking reunification with your children?
Checkboxes
17. What are your childcare plans while in the program?
Checkboxes
18. Are you a veteran?
Client veteran status
Identification
19. Social Security Number:
SSN
20. Do you have a Drivers License and/or ID?
Checkboxes
21. Do you have a birth certificate?
Checkboxes
Contact Information
How can we reach you?
22. What is your email address?
Client email
23. Your primary Contact number? (If you are currently residing within a facility - jail, prison, hospital, detox) please indicate a contact person/case manager that we may contact.
Client phone
24. If you have a permanent address, please provide it below:
Street Address:
Client Address
City:
Client City
State:
Client State
Zipcode:
Client Zip
County of Residence:
Text field
Contacts
Emergency contact: Please list two if possible (family member, case manager, community supervision officer, etc.)
Contact
Living Situation
25. Are you currently incarcerated?
Checkboxes
26. If yes, what is the name of the institution?
Text field
27. If yes, what is your release date/court date/sentiencing date?
Text field
28. What is your living situation?
Checkboxes
29. Who were you living with before entering this program?
Checkboxes
30. What are your living arrangements before entering this program?
LivingArrangementHistory
Employment
31. Are you currently employed?
Checkboxes
32. If yes, where?
Text field
33. Do you currently have any income?
Checkboxes
34. If yes, what is your income?
Checkboxes
35. Please Identify the amount of income
Text field
Insurance
36. If you have insurence, please enter your insurance provider(s).
Insurances
Medical, Substance Use and Treatment History
Tell us about your medical history.
37. What was the first age you used alcohol or other drugs?
Checkboxes
38. When was your last date of use?
RecoveryHistory
39. How much did you use?
Text field
40. Do you require detoxification or hospitalization?
Checkboxes
41. What is your substance(s) of choice? Add multiple by clicking in the box and selecting different options
Client substances of choice
42. What methods have you used to take your substance(s) of choice?
Checkboxes
43. Have you been clinically diagnosed with anything? Add multiple by clicking in the box and selecting different options
Client diagnosis
44. Do you have any health problems? Add multiple by clicking in the box and selecting different options
Client health problems
45. Please list any long-term medical conditions?
Text field
46. What kind of meetings do you attend? Add multiple by clicking in the box and selecting different options
Client kinds of meetings attended
47. What allergies do you have? No allergies? Move on to the next question
Client allergies
48. Do you have any physical or mental health disabilities that prevent you from working?
Checkboxes
49. If yes, please describe (with diagnosis if diagnosis):
Text field
50. Who is your current physician/doctor?
Text field
51. Do you need medical attention?
Checkboxes
52. If yes, please describe your current needs?
Text field
Medications
List the medications you are currently prescribed (write n/a if not applicable).
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53. Are you currently prescribed any of the following medications?
Checkboxes
Treatment Centers
54. Have you previously been in treatment?
Checkboxes
55. If yes, how many times and when/where?
TreatmentCenterHistory
56. Did you leave any treatment Against Staff Advice?
Checkboxes
Client Referral Source
57. Who referred you to us?
Client Referred By
Legal & Community Supervision:
59. Do you have any past or pending legal issues?
Checkboxes
60. If yes describe your charge(s), date(s), and sentence(s):
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61. Are you under community supervision (probation or parole)?
Checkboxes
62. If yes, list your community supervision officer's contact information:
Text field
63. Probation
64. Does your officer know you are seeking treatment
Checkboxes
65. How often are you required to report?
Text field
66. Do you have a public defender or private attorney?
Checkboxes
If yes, list their contact info:
Text field
67. Are you required to register as a sex offender?
Checkboxes
If yes, provide details
Text field
Agreement & Authorization
68. Why are you seeking treatment at Fresh Wind Recovery Ministry?
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69. Any additional notes?
Client notes
70. I give permission to Fresh Wind Recovery to run a criminal background: Initials Text field
71. I hearby declare that all the information I have given in this application is true. I understand that any false information will be grounds for non-admission to or dismissal from Fresh Wind Recovery program. I also understand that submitting this application does NOT guarantee entrance into the Fresh Wind residential program.
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