Recovery Center of the Ozarks - Lead Form

Recovery Center of the Ozarks Application

Thank you for your interest in applying to RCO.

 

Recovery Center of the Ozarks is a non-profit organization focused on providing pathways of hope for those seeking a journey out of substance use disorder while reclaiming their life and reengaging in society. 

The holistic approach of recovery translates not only mentally and physically but aims to strengthen a person emotionally, spiritually, financially, socially and intellectually to improve an individual’s quality of life while building recovery capital for the future.

Each individual in RCO’s program willingly builds a new sense of purpose driven by accountability, self-respect and responsibility highlighting a positively changing identity grounded in the principles of honesty, integrity and selflessness.

 

A better life centered in recovery awaits!

Click next to begin!

General

Tell us about yourself
What is your first name?
Client first name
What is your middle name? No middle name? Move on to the next question.
Client middle name
What is your last name?
Client last name
When is your birthdate?
Client birthdate
What is your race/ethnicity?
Client race
What is your gender?
Client gender
What is your marital status?
Client marital status
Are you a veteran?
Client veteran

Contact Information

How can we reach you?
What is your email address?
Client email
At what phone number can we best reach you at?
Client phone
Street Address:
Client Address
City:
Client City
State:
Client State
Zipcode:
Client Zip

Contacts

Give us a few people that we can reach out to in case of an emergency.
Contact

Insurance

Enter your insurance provider(s).
Insurance

Medical History

Tell us about your medical history.
When was your last relapse date?
Recovery history 1 relapse date
What is your substance(s) of choice? Add multiple by clicking in the box and selecting different options
Client substances of choice
Have you been clinically diagnosed with anything? Add multiple by clicking in the box and selecting different options
Client diagnosis
Do you have any health problems? Add multiple by clicking in the box and selecting different options
Client health problems
What kind of meetings do you attend? Add multiple by clicking in the box and selecting different options
Client kinds of meetings attended
What allergies do you have? No allergies? Move on to the next question.
Client allergies

Have you had any of the following tests?

Medical Tests
 

Medications

List the medications you are currently prescribed.
Paragraph
 
Have you ever or are currently using suboxone?
Text field

Sober Living History

Tell us about any sober living places or treatment centers you've previously been admitted into.
Paragraph

Employment

Tell us about your employment status.
If you're currently unemployed select "unemployed" under "type"
EmploymentHistory

Living Arrangement

Tell us about your living arrangement prior to moving into this facility.
LivingArrangementHistory

Final Questions


Do you have a driver's license?

Text field

Do you have a social security card?

Text field

Do you have your birth certificate?

Text field

Can you pass a drug test? This will not affect our decision to accept your application.

Text field

Do you have any gang relations?

Text field

Do you have a vehicle? Text field
If yes, Make/Model? Text field Make/Model Text field
Do you have valid vehicle insurance? Text field
Do you have any pending criminal charges? If yes, please explain.

Paragraph

Why are you pursuing Recovery Center of the Ozarks?

Paragraph

What are your biggest concerns about entering into a recovery program?

Paragraph

 

Thank you for completing the application.

Recovery Center of the Ozarks looks forward to speaking with you and will be in touch at the phone number or email you provided. Until then, keep your head up and know that a life absent of substance use is possible and the resources exist in your area to provide you all the help you need to recover.