AGGATE RECOVERY RESIDENCE
Standing at the start of a new chapter in recovery, you deserve a supportive, empowering environment to nurture your sobriety. Here at the Aggate Recovery Residences, we're more than just a housing provider – we're your trusted partner in achieving a life enriched by recovery. We understand the unique challenges you face, and we're dedicated to creating a welcoming, structured space where you can cultivate lasting well-being, build meaningful connections, and rediscover your potential.
Our commitment to your success starts with understanding your needs. While HIPAA regulations ensure the utmost privacy and confidentiality of your information, knowing a little about your background and circumstances allows us to tailor our support to perfectly fit your journey. Think of it as opening the door to a personalized roadmap for thriving in sobriety. We'll never ask for anything beyond what's essential to provide the most optimal environment for your growth and comfort.
So, take a deep breath and step into the vibrant community of Aggate Recovery Residences. Here, you'll find a network of fellow travelers walking similar paths, offering encouragement and shared experiences. Our dedicated staff, seasoned in supporting recovery, provides guidance and resources without judgment, fostering a safe space where you can truly be yourself.
Ready to write a new chapter of strength and connection? Let's embark on this empowering journey together. We'll walk alongside you every step of the way, ensuring your privacy and confidentiality while building a haven for your continued sobriety.
Entrance into the Aggate Recovery Residences require the downloading of the One Step Application
Welcome to the AGGATE RECOVERY RESIDENCE Intake Wizard
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Personal information
Tell us about yourself
Please complete all Questions Below
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
What is your birthdate?
Client birthdate
last 4 digits of your social security number
SSN
What is your Monthly Gross Income,
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What is your Monthly General Assistance
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What is your Monthly Food stamps
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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 status
Tell us about yourself, what you like and do not like
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Medical History
Tell us about your medical history.
What is your sober date
Date
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
Vaccinations
Vaccines
Treatment Centers
Current Treatment Center
Tell us about the treatment center you are attending
TreatmentCenterHistory
Counselor Name, Email, Phone Number
Contact
Occupancy
Estimated length of stay?
Client estimated length of stay
Estimated discharge date?
Client discharge date
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.