Hope Recovery Focus Program Application

Thank you for your interest in Hope for NH Recovery's Focus Program. Please answer the following
questions honestly and completely. All information provided will be kept confidential and used to
determine your eligibility and placement within the program. The application consists of 8 sections.

 

Section 1: Personal Information

Full Name:

Client first nameClient last name

Nickname:

Client nickname

Date of Birth:

Client birthdate

Current Address:

Client Address

Phone Number:

Client phone

Email:

Client email

Gender:

Client gender Pronouns:Client pronoun

What is your sobriety date?: 

Date

Are you currently a member of Hope for NH Recovery?

Radio buttons If yes, when did you become a member?Date

Section 2: Substance Use History

Primary Substance of Use:

Client substances of choice

Secondary Substance of Use (if applicable):

Client substances of choice

RecoveryHistory

Age of First Use:Number field

Length of Time Using Regularly:Text field

Have you experienced any overdoses? 

Radio buttons If yes, how many?Number field

Have you experienced any withdrawal symptoms? 

Radio buttons If yes, please describe:Text field

Have you attempted to stop your use before? 

Radio buttons If yes, please describe your previous attempts and outcomes:Text field

Section 3: Justice Involvement History

Have you ever been arrested or convicted of a crime? Criminal History If yes, please provide details (dates, charges, outcomes):Text field

Have you ever been arrested or convicted of a crime related to sexual misconduct, violent offenses, or
arson? 

Radio buttons If yes, please provide details (dates, charges, outcomes):Text field

Are you currently on probation or parole? Probation 

Do you have any pending legal matters?

Radio buttons If yes, please provide details:Text field

Section 4: Rehabilitation History

Have you ever participated in a formal substance abuse treatment program?

Radio buttons

TreatmentCenterHistory

Have you participated in any recovery support groups (e.g., AA, NA, SMART Recovery)? 

Client kinds of meetings attended

Are you currently working with a sponsor or counselor? 

Client sponsor If yes, please provide details:Text field

Section 5: Employment and Income

Radio buttonsText field

EmploymentHistory

If unemployed, what is your primary source of income?

Text field
Do you receive any financial assistance (e.g., TANF, disability)? 

Radio buttons If yes, please specify:Text field

Section 6: Medications and Health

List all current medications (prescription and over the counter):Text field
Do you have any medical conditions? 

Client health problems

Do you have any mental health conditions? 

Client diagnosis

Do you have any allergies? 

Client allergies

Do you have any dietary restrictions? 

Text field

Section 7: Program Needs and Preferences

What are your expectations for a recovery program?Text field
Do you have any preferences regarding location or type of program?Text field
Are you willing to participate in community activities and program meetings? Radio buttons
Do you have any transportation needs?Text field
Do you have any other needs or concerns you would like to address?Text field

Section 8: References (Optional)

Contact

 

Statement of Accuracy:

I certify that the information provided in this application is true and accurate to the best of my knowledge. I
understand that providing false information may result in disqualification from the program.

Signature:Signature

Date:Date

Thank you for your application.
We will review your information and contact you shortly