Tabula Rasa Resident Application
Tabula Rasa will review your application and make a decision regarding residency using the information you provide below. We do not and will never discriminate against potential residents based on race, sex, gender identification, sexual orientation, national origin, native language, religion, age, disability, marital status, citizenship, genetic information, pregnancy or any other characteristic protected by law. If you feel that you have been discriminated against, please contact the Director of Operations for Tabula Rasa using contact information found on the Tabula Rasa website or contact the New Hampshire Coalition of Recovery Residences through their website.
Date: Date
First Name:Client first name Last name: Client last name
Date of Birth: Client birthdate Requested Date of Move-In: Date
Home Address:Client AddressClient CityClient StateClient ZipCurrent Phone Number:Client phone
Current Email:Client email
Marrital Status: Client marital status
TREATMENT HISTORY:
Have you lived at Tabula Rasa before:Dropdown
If yes, please list the dates: Arrived: Text field Departed:Text field
Who referred you to Tabula Rasa: Client Referred By
Please provide your current and past treatment facilites:TreatmentCenterHistory
Please list your past sober living residences: SoberLivingHistory
Have you ever participated in a 12-Step program in the past:Dropdown
If yes, what step are you currently working on?Client step
Do you have a sponsor?Dropdown
If yes, what is their name?Text field
SUBSTANCE ABUSE HISTORY:
Date of last use:Date
Drug of Choice:Text field
Have you abused perscription medications in the past?Dropdown
What is your longest period of abstinence:Text field
Dropdown
When was your most recent drug screening?Date
Do you smoke tobacco or nicotine products:Dropdown If yes, how much daily?Text field
MENTAL HEALTH TREATMENT HISTORY:
Have you ever been treated for a diagnosed mental health conditions?Dropdown
If yes, please select all diagnosesClient diagnosis
Were you hospitalized for any of these diagnosises?Dropdown
Do you currently take medication?Dropdown
Please list the medication and dose:Medication
Have you seriously thought of, planned or attempted suicide?Dropdown
Are you currently on a Medication Assisted Recovery plan?Medication
If yes, what medication are you on?Text field
Medical/Physical Condition:
Client health problems
Employment History/Financial Resources:
Are you currently able to work full time (40 hours/week):Dropdown
Please list the kinds of jobs you had in the past:Text field
Are you currently on public assistance?Dropdown
If no, what is yourcurrent source of income?Text field
Are you a veteran of the U.S. Military?Dropdown
If yes, which branch?Dropdown
Family History:
Please list the members of your family in which you grew up that have had substance abuse issues:
Paragraph
Do you have dependent children?Dropdown
If yes, do you have custody or a visitation order in place?Dropdown
Education History:
EducationHistory
Legal History:
Past Legal Issues:
Please list any past charges, convictions, prison sentences, DWI, probations, paroles, etc.
Paragraph
Current Legal Issues:
Please list any current charges, court cases pending, probation, etc. that you are facing:
Paragraph
Please include name, office and telephone number of any parole or probation officer following your case.
Paragraph
Personal Statement:
Briefly explain what you expect to gain from becoming a member of Tabula Rasa.
Paragraph
Briefly explain what you can offer Tabula Rasa and its current residents.
Paragraph
Other comments:
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Financial Information:
Housing fees for Tabula Rasa are currently set at $750.00 per month or $175.00 per week. Housing fees include a furnashed bed space (bed, night stand, shared dresser and shared closet), utilities, internet, live cable streaming service, free washer and dryer, household goods to include papertowels, toilet paper and coffee. The resident is responsible for personal toiletry items and food.
Tabula Rasa does charge a non-refundable fee of $100.00 at the time of move-in. The resident will recieve a copy of the Big Bool, a notebook, a Tabula Rasa tee shirt, and a tote bag.
Refunds for any portion of the housing fees that are due to the resident at the time of seperation will be returned within 5-7 business days. Refunds will not be granted for any reason if the resident does not follow the Tabuka Rasa seperation policy, which would include scenarios such as a failed UA, relapse or violation of house rules that result in the Tabula Rasa leadership enforcinga separation with the resident.
From time to time, residents will recieve scholarships from third party payers that help to cover move in fees or housing costs. Tabula Rasa will provide notification, in writing, to the resident when any payment is made by a third party on their behalf.Initials Text field
I attest that I have read, in full, and understand the information in this application. My signature below indicates my interest in becoming a resident at Tabula Rasa.
Signature:Signature
Date:Date