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: 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:
Have you ever lived in a recovery residence:
What is the longest length of sobriety that you have had: Text field
From what city and state will you be moving: Text field
Which valid forms of identification do you have:
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):
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:
Do you have any pre-existing mental, emotional, and/or physical conditions:
List all medications you are currently taking:
Do you have a Legal vehicle that you actually drive:
Do you have a job?
What is you job title and description?
Do you have any pending charges, court dates, or outstanding warrants:
Do you have any children:
Will you need to apply for food stamps or renew any forms of identification:
What is are your motives for seeking recovery residency:
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?
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