PRE-ADMISSION SCREENING FORM
28-Day Faith-based 12-Step Residential Program
SECTION 1: About Client
Resident Full Name: Client first nameClient middle nameClient last name
Age:Text field
Phone Number:Client phone
Current Location (City/State): Client CityClient State
Name of Detox/Behavorial Health Reffered by:
Text field
SECTION 2: IMMEDIATE ELIGIBILITY SCREEN
Is the individual male and 18 years or older?
Checkboxes
Is he currently under the influence at this time?
Checkboxes
Does he require medical detox?
(Shakes, seizures, hallucinations, history of severe withdrawals?)
Checkboxes
Is he currently prescribed MAT (Suboxone, Methadone, etc.)?
Checkboxes
**Please Know if Selecting Yes on MAT a requirement of 30-Day Prescription is a must to be admitted into the program**
Any history of violence or aggressive behavior?
Checkboxes
(Explain): Text field
Any active psychosis or untreated severe mental illness?
Checkboxes
SECTION 3: SUBSTANCE USE HISTORY
Primary substance of choice: Text field
How long using? Text field
Last use date: Text field
Average daily use: Text field
History of overdose?
Checkboxes
Previous treatment attempts?
Checkboxes
Number of prior treatments: Text field
SECTION 4: LEGAL STATUS
Is he currently on:
Checkboxes
Is treatment court-ordered?
Checkboxes
Any violent felony history or sex offender registry?
Checkboxes
SECTION 5: MENTAL HEALTH SCREEN
History of diagnosed mental illness?
Client diagnosis
History of suicide attempts?
Checkboxes
Any current suicidal thoughts?
Checkboxes
SECTION 6: PROGRAM UNDERSTANDING
Resurrected Recovery is:
28-day residential
Faith-based
12-Step focused
Structured schedule
Mandatory class attendance
Nightly outside AA meetings
MAT accepted / with prescription
Private pay only / No insurance needed
No refunds
Please note that this program is not free, and the total cost is $4,000. However, we are deeply committed to ensuring that financial challenges do not stand in the way of anyone seeking recovery and support.
Scholarships are available based on individual applications. For those who qualify, financial assistance ranging from 25% to 50% of the program cost may be offered, depending on income and circumstances.
If you are in need of financial support, please indicate “yes” on your application and include a brief explanation of your situation. We encourage you to share why entering recovery is essential for you at this time and why you would like to be considered for a scholarship.
Our goal is to make this program accessible to those who truly need it, and we are here to work with you to explore available options.
If you are unable to pay the full cost of the program and would like to apply for a scholarship to help cover a portion of the treatment? Please select Yes or No.
Checkboxes
If you are applying for a scholarship, please provide a detailed explanation of why entering recovery is essential for you at this time and why you believe you should be considered for financial assistance. We encourage you to share your current circumstances, your commitment to recovery, and how this program will support your goals.
Please note that all submissions will be carefully reviewed by our team and local partners to determine eligibility for scholarship support. List response Below.
Paragraph
Are you willing to participate in a Faith-based program?
Checkboxes
Are you willing to attend nightly AA meetings?
Checkboxes
Are you willing to follow house rules strictly?
Checkboxes
Are you willing to remain abstinent and submit to drug testing?
Checkboxes
SECTION 7: MOTIVATION & READINESS
Why are you seeking treatment right now?
Paragraph
On a scale of 1-10, how committed are you to change?
Text field
What happens if you don't enter treatment?
Paragraph
SECTION 8: Medical STABILITY
Any current medical conditions requiring monitoring?
Checkboxes
Any recent hospitalizations?
Checkboxes
Currently detoxed and medically stable?
Checkboxes
Please list any medications the resident is currently taking along with proper dosing, down below.
Medication