LifeGate Freedom Recovery Ministries
Application for Residency
Today's Date: Date
Name: Client first nameClient middle nameClient last name
Date of Birth (mm/dd/yr): Client birthdate Age: Text field
Previous or permanent Address: Client Address
City: Client City State: Client State Zip: Client Zip
Cell Number: Client phone
E-mail: Client email
Homeless:Text field How Long? Text field
Veteran: Client veteran status
Do you need to obtain a copy of your SS:
Radio buttons
License or ID:
Radio buttons
Birth Certificate:
Radio buttons
Social Security Number: SSN
Driver’s License or ID #: Text field
Emergency Contact: Contact
Emergency contact phone number: Text field
Do you currently have insurance? Insurances
Highest level of education completed: EducationHistory
Are you on Probation or Parole?
Radio buttons
If yes, who is your Probation Officer? Probation
Probation Officer Phone Number: Text field
Are you sentenced to this program?
Radio buttons
If yes: by what court?
Text field
DOC#Text field
Type of release:
Radio buttons
Expected date of arrival: Client discharge date
Case Manager’s name if incarcerated: Text field
Facility: Text field
Phone Number: Text field
Reason for incarceration: Text field
Choose one:
Radio buttons
Are you now or have you ever been affiliated with a gang?
Radio buttons
If yes what organization?
Text field
Sex Offender?
Radio buttons
Any charges pending?
Radio buttons
If yes, please list: Text field
Marital status: Dropdown
Name of Spouse: Text field
How many children? Text field
Ages: Text field
Names: Text field
Who do the children stay with? Text field
Do you have children in DHS custody?
Radio buttons
Do you have a reunification plan with your children through the courts?
Radio buttons
Are you a veteran?
Radio buttons
Employment History:
Are you currently employed?
Radio buttons
If not employed when was the last time you were employed?
Text field
What type of work have you done in the past?
Text field
Company Name, address and phone number:
Paragraph
Do you have a personal vehicle that will be on our property?
Radio buttons
If so, Year Text field Make Text field
Model Text field
Vehicle Insurance Verification: Text field
Medical History
Physician Name: Text field
Phone Number: Text field
Are you currently enrolled for services in any mental health facility or organization? i.e. Creoks, Family and Children's Services, Grand Addiction Recovery Center, Human Skills and Resources? If so please list who with: Text field
The information below will be used to obtain records in order to help us assess your needs.
Race:
Client race
If Native American what tribe:
Ethnicity: Client ethnicity
Sex:Client gender
Pronouns:Client pronoun
Are you currently on disability?
Radio buttons
Have you applied for disability at this time? If so when?
Radio buttonsDate
Are you receiving a check for disability?
Radio buttons
If yes, how much are you receiving each month? Text field
Do you have any physical limitations that keep you from performing manual labor?
Radio buttons
If yes, please explain:
Client medical notes
Family History: Alcoholism or Drug addiction (please list all known relatives with either of these problems)
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Have you ever used drugs intravenously? (Shot Drugs)
Radio buttons
Have you ever had a blood transfusion?
Radio buttons
Please give a complete history of your alcohol and drug use:
Paragraph
Substances of choice:Client substances of choice
Sobriety date: Text field
How long have you been completely clean at this time? Text field
Do you need physical detox?
Radio buttons
if yes, please explain:
Paragraph
Please list all medical problems that you have been diagnosed with including mental health issues:
Client diagnosis
What medications are you currently taking, please list each one:
Medication
Are you currently taking any of the following medications for help with your substance use disorder?
Buprenorphine Or Suboxone:
Radio buttons
Naltrexone:
Radio buttons
If yes then please list prescribing agency:Text field
List any Allergies: medications or environmental (Cats, Foods, etc.)
Client allergies
Do you have epilepsy?
Radio buttons
Type: Text field
Do you wear prescription glasses or contacts?
Radio buttons
Do you have any dental complaints that need attention now?
Radio buttons
Mental Health History
As a part of our services our staff is trained as Peer Recovery Support Specialists. Are you willing to sign up for these services?
Radio buttons
Do you express your feelings easily?
Radio buttons
Would you rather be around people or alone?
Text field
Have you lived in close quarters with other people?
Radio buttons
Do you have trouble sleeping?
Radio buttons
If yes, please explain:
Paragraph
Do you suffer from nightmares on a regular basis?
Radio buttons
if yes, please explain:
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Have you ever suffered a severe emotional trauma?
Radio buttons
If yes, please explain:
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Have you ever tried to commit suicide or thought about it on a frequent basis?
Radio buttons
If yes, please explain:
Paragraph
Have you ever been in counseling before?
Radio buttons
If yes, please explain:
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Has you been diagnosed you with any emotional disorders?
Radio buttons
If yes, please explain:
Client diagnosis
Have you ever been hospitalized for an emotional problem?
Radio buttons
If yes, please explain:
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Are you willing to release any mental health records to LifeGate Freedom Recovery Ministries?
Radio buttons
Have you ever been molested?
Radio buttons
If yes, was it by a family member?
Radio buttons
Have you experienced human trafficking either willingly or unwittingly?
Radio buttons
Have you ever been involved in any activities that you know were demonic?
Radio buttons
If yes, please explain:
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Have you ever thought that you may have exposed yourself to demonic spirits?
Radio buttons
If yes, please explain:
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Have you ever been in a religion that others have told you that it was an occult?
Radio buttons
If yes, please explain:
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Why do you want to be a participant in the program?
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What goals do you hope to achieve while in the program?
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What is your #1 priority?
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How can we help you to achieve your goals?
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Do you understand that this is a faith-based program?
Radio buttons
If yes, explain what you believe that means about this program:
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Can you get along with roommates?
Radio buttons
If no, please explain why:
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Program History: List all programs that you have entered into and the dates you were there and whether or not
you completed the program. Why were you there and why did you leave?
Paragraph
Signature:
Signature
Date: Date
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