New Resident Application

Name: Client first nameClient last name

Date of Birth: Client birthdate

Email: Client email

Phone: Client phone

At what facility are you currently being treated: Text field

Case Manager/Discharge Planner Name and Phone Number and email (All of the above): Text field

Best way to get back in touch with you: Text field

What is your discharge date: Date

When & where have you been treated for substance abuse in the past: 

Paragraph

Have you ever lived in a recovery residence: 

Radio buttons

What is the longest length of sobriety that you have had: Text field

From what city and state will you be moving: Text field

Do you have a Valid Driver's License and do you currently have posession of it?

Checkboxes

Do you have a State ID, and do you currently have possession of it? 

Checkboxes

Do you have a Social Security Card, Birth Certificate, or Passport and do you currently have possession of any of these?

Checkboxes

What state were you born? 

Text field

Primary substance of choice:

Client substances of choice

Date of last use: Date

Secondary substance of choice: Text field

Date of last use: Date

Will you be attending outpatient rehab (IOP):

Radio buttons

How many times have you attended inpatient rehab: Text field

How many times have you attended outpatient rehab: Text field

Are you seeking residence at Threshold Recovery of your own volition, or is this residency recommended by probation or TDOC: Text field

Have you worked a 12-step program: 

Radio buttons

Do you have any pre-existing mental, emotional, and/or physical conditions: 

Radio buttons

List all medications you are currently taking: 

Medication

Do you have a legal vehicle that you (actually) drive: 

Radio buttons

Do you have a job?

Radio buttons

What is your job title and description?

Text field

Do you have any pending charges, court dates, or outstanding warrants: 

Radio buttons

Do you have any children: 

Radio buttons

Will you need to apply for food stamps or renew any forms of identification: 

Radio buttons

What are your motives for seeking recovery residency: 

Paragraph

What is your expected length of stay at Threshold Recovery: Text field

Who will be covering the cost of your lease at Threshold Recovery, you or someone else? 

Radio buttons

If someone else... 
Payer Contact Name: Text field

Payer Contact Number: Text field

My signature below confirms my understanding and agreement to the following terms:I must be fully detoxed and able to pass a drug screen & breathalyzer upon my arrival to Threshold Recovery.
I agree to abstain from mood-altering substances, which can result in injury, coma, or death during my residency.
I agree to weekly random drug and alcohol screens.
I understand that any violation, on my behalf of Threshold Recovery’s zero-tolerance policy for drug and alcohol use, will result in my immediate dismissal.
I also understand and agree to pay the financial requirements upon my arrival and throughout my residency at Threshold Recovery.

My signature below verifies that this application was accurately completed by: Text field

 

Signature: Signature