Application for Women's Recovery Program
Valley Rescue Mission
Name: Client first nameClient middle nameClient last name Nickname: Client nickname
Address:Client Address
Email: Text field
Phone Number:Client phone
Birthdate:Client birthdate Age:Number field
Emergency Contact:Text field Phone Number:Number field
Sex:Text field
Do you know or are you acquainted with anyone connected to Valley Rescue Mission?Text field
Do you have any family in the Muscogee county area?Text field
Who referred you?Text field
Why are you applying to our Program at this time?Text field
What are your immediate needs?Text field
What are your present goals?Text field
What are your: strengths?Text field
What are your weaknesses?Text field
Do you have a valid driver's license? Text field
Do you have a copy of your birth certificate?Text field
Do you have a copy of your social security card?Text field
Have you ever been arrested?Text field
If so, what were your charges and the arrest date?Text field
Are you on Probation/Parole?Text field
Probation/Parole Office/Officer Info:Probation
Are you a registered sex offender?Text field
If so, were you convicted on or after July 1, 2008?Text field
Have you ever attempted suicide?Text field
If so, when?Text field
Do you have current suicidal thoughts?Text field
If so, when?Text field
Have you been hospitalized for emotional or nervous reasons?Text field
Have you every been in Therapy?Text field
If so, were medications prescribed?Text field
If currently in therapy, please list therapist name:Text field
Who is your primary Physician? Text field
Are you currently on any medication?Text field
If so, please list:Text field
Have you had any major surgeries in the last 5 years?Text field
Do you have any upcoming major surgeries?Text field
Please provide the following information:
Family MembersEmploymentHistoryEducationHistoryRecoveryHistoryTherapist/ClinicianClient sponsor
What is the highest level of education completed?Text field
Are you a Veteran?Text field
Ever received housing assistance?Text field
Do you owe the Housing Authority money?Text field
Are you presently homeless?Text field
Are you currently receiving Medicare/Medicaid, disability or other Government aid?Text field
Are you on food stamps/EBT?Text field
If selected for residence in this program, is there anything that we should know about you that would hinder your ability to sweep, mop, lift, mow, or do normal household chores?Text field
Have you ever struggled with addiction?Text field If not, Please leave this section blank.
Drug of choice:Text field Age of firt use:Number field Longest period of sobriety:Number field
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Amount/How Often
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Date First Used
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Date Last Used
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Cocaine/Crack
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Date |
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Marijuana
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Date |
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Heroin
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Date |
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Alcohol
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Fentanyl
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Nicotine
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Date |
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Prewcription Drugs
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Date |
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Methamphetimines
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Date |
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Kratom
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Date |
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Spice
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Date |
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Other
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Date |
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Do any of these apply to you?
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Childhood
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Teen
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Adult
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Currently
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In therapy For
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Escaping
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None
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Physical Abuse
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Emotional abuse
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Sexual abuse
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Financial Abuse
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Victim of Human Trafficking
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Are you currently experiencing or diagnosed with:
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Yes
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Headaches
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Difficuty Hearing
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Vomiting
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Hemmothoids
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High Blood Pressure
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Low Blood Pressure
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Wear Prosthetic
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Sores or Open Wounds
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Dental Issues
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Diarrhea
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Palpitations
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Numbness
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Use Walking Device
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Lomglasting Sores
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Frequent Ear Aches
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Heartburn or Gas
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Constipation
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Shortness of Breath
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Weakness
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Fatigue
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Joint Pain
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Bruise Easily
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Lice
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Crabs
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Painful Urination
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Vision Issues
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Hearing Aide
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Dizziness
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Abdominal Pain
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Cramping
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Chest Pain
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Neck Pain
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Shoulder Pain
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Back Pain
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Skin Irratation
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Current Injury
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Frequent Urnation
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Unusual Discharge
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Withdraw
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Blackouts
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Mumps
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Renal Issues
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Cancer
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Mental Illness
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Emotional Abuse
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Herpes
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Hallucinations
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Rhematic Fever
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Liver Problems
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Hapatitis
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Heart Disease
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Physical Abuse
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Gonorrhea
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Delirium Tremens (DT's)
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Jaundice
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Arthiritis
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Stroke
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TB
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Syphillis
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Seizures
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Typhoid
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Ulcers
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Diabetes
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Tuberculosis
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Sexual Abuse
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HIV
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AIDS
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Please give a little background about yourself and why you feel this is the right program for you.Paragraph
NOTE: This center is not a medical or psychiatric facility: therefore, prospective clients must be medically, as well as, psychiatrically cleared prior to admission. The requested medical information within this application for consideration of admission form is vitally important and is required before a decision can rendered as to the appropriateness of our facility for prospective clients. If mental health evaluation / documentation is requested, that also must be received before a final decision can be made regarding placement in the Recovery Program. If, within 30 days of admission, it is noted that the client is inappropriate due to medical or psychiatric reasons about which we were uninformed prior, this facility reserves the right to refer the client to another facility or back to the referring agency.
By signing below you give Valley Rescue Mission the consent to collect data electronically which may contain medical information, PHI or other sensitive data, for the intended use stated above.
By signing below you understand your information will be shared/stored in One Step. a client database software program.
By signing below you are consenting to the information on thiis form being used by Valley Rescue Mission staff for screening purposes, program purposes and upon request shared with law enforcement or goverment agencies as require by law.
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.
Siignature:Signature Date:Date
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