Resident Applicant Information

Date: Date

Desired Date to Move into Redemption by Grace: Date

Name: Client first nameClient last name

Gender: Dropdown

DOB: Client birthdate

SSN: SSN

Phone: Client phone

Email: Client email

Current Mailing Address: Client AddressClient CityClient StateClient Zip

Do you own or rent: Dropdown

Monthly Payment: Text field

How Long: Text field

Monthly Gross Income: Text field

Do you receive SSI: Radio buttons

Are you able to work? Radio buttons

Martial Status: Client marital status

Level of Education: EducationHistory

Are you a Veteran? Client veteran status

Are you Pregnant?Radio buttons

Do you have a valid Driver's license? Radio buttons

Do you have a car? Radio buttons

Is it registered and insured? Radio buttons

How did you hear about Redemption By Grace? 

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Recovery and Substance Use Information

Do you need help with alcohol: Text field  If yes, How long: Text field

Do you need help with drugs: Text field If yes, How long: Text field

Primary Substance: Client substances of choice Date of last use: Date

Substance of choice:Client substances of choice How long have you been in Recovery? RecoveryHistory

Do you have a sponsor? Yes / No When was the last time you were in clinical treatment? Client sponsor TreatmentCenterHistory

How long were you in treatment? Text field

 

Emergency Contact Information

Contact #1

Name: Text field Relationship:Checkboxes

Phone: Text field

Address: Text field

Contact #2

Name: Text field Relationship:Checkboxes

Phone: Text field

Address: Text field

Contact #3

Name: Text field Relationship: Checkboxes

Phone: Text field

Address: Text field

Legal Information

Have you been arrested in the past 30 days? Radio buttons

If yes, please explain:

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Are you currently on probation or parole? Radio buttons

If yes: Probation/parole Officer: Probation

Phone: Text field

Are you court-ordered to treatment? Radio buttons

Please describe any other legal problems (Court dates, warrants, active restraining orders, etc.)

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Medical Information

Do you take any prescription medications? Radio buttons

List of Medications: Medication

Do you have any medical conditions or allergies? Radio buttons

Client allergies

Client health problems

Are you on any MAT or maintenance programs? Radio buttons

If Yes, Medication

If yes, when was the last time you took MAT? Date

 Have you ever had a mental health diagnosis? Radio buttons

What was your diagnosis? Text field

Are you currently on any mental health medication? Radio buttons

If yes, please list medications:

Text field

 

Please list any other relevant medical information:

Client medical notes

 

Please describe your recent work experience: EmploymentHistory

 

Have you ever been charged with or been convicted of a sex crime? Radio buttons

 

I authorize the verification of the information provided in this form. If anything I have said is found to be untrue I acknowledge that will be sufficient for immeditate removal from the Redemption By Grace program.

Initials Text field

 

Signature: Signature

 

Date: Date