Application

Sullivan House Application

Welcome to the Sober Homes intake wizard
Click next to begin!

General

Tell us about yourself
What is your first name?
Client first name
What is your middle name? No middle name? Move on to the next question.
Client middle name
What is your last name?
Client last name
When is your birthdate?
Client birthdate
What is your race/ethnicity?
Client race
What is your gender?
Client gender
What is your marital status?
Client marital status
Are you a veteran?
Client veteran status

Contact Information

How can we reach you?
What is your email address?
Client email
At what phone number can we best reach you at?
Client phone
Street Address:
Client Address
City:
Client City
State:
Client State
Zipcode:
Client Zip

Contacts

Give us a few people that we can reach out to in case of an emergency.
Contact

Insurance

Enter your insurance provider(s).
Insurance

Medical History

Tell us about your medical history.
When was your last relapse date?
Recovery history 1 relapse date
What is your substance(s) of choice? Add multiple by clicking in the box and selecting different options
Client substances of choice
Have you been clinically diagnosed with anything? Add multiple by clicking in the box and selecting different options
Client diagnosis
Do you have any health problems? Add multiple by clicking in the box and selecting different options
Client health problems
What kind of meetings do you attend? Add multiple by clicking in the box and selecting different options
Client kinds of meetings attended
What allergies do you have? No allergies? Move on to the next question.
Client allergies

Have you had any of the following tests?

Medical Tests
 

Medications

List the medications you are currently prescribed.
Medication

Treatment Centers

Tell us about any treatment centers you've previously been admitted into.
TreatmentCenterHistory

Client Referral Source

 
Who referred you to us?
Client Referred By

Occupancy

 
What facility will you be staying at?
Client facility
What date will you be admitted on?
Text field
What is the estimated length of stay?
Client estimated length of stay
 

Sober Living History

Tell us about any sober livings you've previously been admitted into.
SoberLivingHistory

Employment

Tell us about your employment status.
Do you have a current job near the Sullivan House, and if not, what field of work are you interested in?
Paragraph
 
If you are unemployed and unable to work, what are your plans for income?
Paragraph

Living Arrangement

Tell us about your living arrangement prior to moving into this facility
LivingArrangementHistory

 

Release of Information

 

Text field                                                    Number field                

Client’s Name                                            Date of Birth

 

I Text field  authorize the Sullivan House to release information below to Sullivan County Manager and Administrative staff for the purpose of managing, financing and planning for Sullivan House.

 

The following information:                                                           

Initials Text field Name                             

Initials Text field Application                                                         

Initials Text field Date of Birth                                                                

Initials Text field Verbal exchange of information                               

Initials Text field Eligibility for Sullivan House

Initials Text field Drug/Alcohol test results                       

 

Initials Text field  I understand that the information released may include HIV, Substance Use Disorder or other health

               care information.

Initials Text field  I understand that this information may also be faxed or emailed to/from above named program or

               individual.

 

I understand that my alcohol/drug treatment records are protected by Federal Regulations governing Confidentiality of Substance Use Disorder Patient Records (42 C.F.R Part 2) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R parts #160 & 164 and cannot be disclosed without my written consent unless otherwise provided for in the regulations.  I also understand that I may revoke this consent in writing at any time except to the extent that action has been taken in reliance on it.  This consent/authorization shall be valid for one year from the date below or 30 days post termination of services.

 

I understand that my treatment may not be conditioned on whether I sign a consent form.  I certify and acknowledge that this release is signed voluntarily. 

 Signature

 

 

This information has been disclosed to you from records protected by Federal Confidentiality Rules (42 CFR, Part 2),  And Health Insurance Portability and Accountability Act of 1996 (HIPAA), The federal rules prohibit you from making any further disclosure of this information unless further disclosure is  expressly permitted by warren consent of the person whom it pertains, or as otherwise permitted under 42 CFR Part 2.  A general authorization for the release of medical and other information is NOT sufficient for this purpose.  The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug patient.  (52 FR210609 June1987, 52 FR 41977, Nov 2, 1987)