Application/Intake Form

 Grace Recovery Home Application/Intake

This Application may take 2-3 business days to review before a staff member contacts you
Click "Next" to begin! 

General

Tell us about yourself
What is your first name?
Client first name
What is your middle name?
Client middle name
What is your last name?
Client last name
When is your birthdate?
Client birthdate
What is your race/ethnicity?
Client race
Education Level Accomplished:
Text field
Social Security Number:
SSN
What is your gender?
Client gender
What is your marital status?
Client marital status
Do you have a significant other?
Dropdown
If yes, please provide their name, address, and phone number:
Text field
Do you have children?
Dropdown
If yes, name(s) and age(s):
Text field
Tell us a little bit about yourself: 
Paragraph

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
Drivers License Number:
Text field
State:
Client State
Expiration Date:
Date
State Issued/Passport Number:
Text field

Contacts

Give us a few people that we can reach out to in case of an emergency.
Contact
 
Client Referral Source
 
Who referred you to us?
Client Referred By Text field

Insurance

Enter your insurance provider(s).
Insurances

Preferred Hospital:Text field 

Medical History

Tell us about your medical history.
When was your last relapse date?
Recovery history 1 relapse date
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? 
Client allergies

Have you had any of the following tests?

Checkboxes 
 
Did you test positive for any of the above tests?
Dropdown
If yes, which one(s)?
Text field

History of Seizures? Checkboxes

If yes, last seizure date: Text field 

Overdosed? Dropdown

If yes, how many times?Text field

Suicide attempts:Dropdown

If yes, number of attempts:Text field

If yes, date of last attempt: Text field

Medications

List the medications you are currently prescribed.
Medication
     
Known medical issues:  
Paragraph
Do you have refills?
Dropdown
If yes, how many?
Text field

Treatment Centers

Tell us about any treatment centers you've previously been admitted into.
TreatmentCenterHistory
 
What do you need assistance with (select all that apply):
Checkboxes
Have you ever participated in MAT (Medical Assisted Treatment)?
Dropdown
If yes, what MAT was used?
Text field
Year:
Text field
How long on MAT (months)?
Text field
Drug(s) of choice:
Client substances of choice
Other drugs/alcohol used in last 6 months: 
Client substances of choice
Detox completed?
Dropdown   
Where:
Text field 
When:
Text field
Sobriety/Clean date:
Date
Longest period sobriety:
Text field  
Length of most active use was:
Text field 

Criminal History

 All Residents are subject to a criminal background check prior to move in. 

Felony(s):Dropdown

If yes, please explain: Paragraph

Are you part of any specialized courts? (DUI, DRUG, MENTAL HEALTH, VETERANS) Dropdown

Drug/Alcohol required testing: Dropdown

On Parole (State/Federal): Dropdown

If yes, please explain: Paragraph

PO name:Text field

Phone #: Client phone

On Probation(county):Dropdown

If yes, please explain: Paragraph

PO/PBO Name:Text field

Phone #:Client phone

DUI (DWI):Dropdown

# of times:Text field

What state(s):Text field

Date(s) MM/DD/YYYY:Text field

Any kinds of pending charges? Dropdown

If yes, what charges?Text field

Registered Sex Offender:Dropdown

Do you have any charges of assault on record?Dropdown

If yes, please explain: Paragraph

Any past use of substances listed? (Please select all that apply): 

Checkboxes

 

 

 

Occupancy

 
Have you lived in a Recovery Home before? If yes, name and location:
Text field
If yes, when:
Text field
Did you have a successful discharge? Please explain:
Paragraph
Have you been to a Residential Program before? If yes, name and location:
Text field
If yes, give the date of completion:
Text field
Did you have a successful discharge? Please explain:
Paragraph
What is the estimated length of stay at Grace Recovery Home?
Client estimated length of stay
Do you have a means of transportation?
Dropdown
If yes, what type (make, model, color):
Text field
License Plate Number:
Text field

Sober Living History

Tell us about any sober living homes you've previously been admitted into.
Have you ever worked a 12-step program of recovery?
Dropdown
If yes, which one (please include Sponsor's name and phone number)?
Text field

Employment

Tell us about your employment status.
If you're currently unemployed select "unemployed" under "type"

Able to work (FULL OR PART TIME):

Dropdown
If no, explain:
Paragraph
Current or Most Recent Employer:
Text field
Employer Address:
Client Address
Employer's Phone Number:
Client phone
Are you on disability:
Dropdown
Do you have a service animal?
Dropdown

Statement of Cooperation

Disclaimer and Signature

I understand that this program requires residents to remain drug and alcohol-free, participate in a recovery program, work with a Peer Recovery Coach, pay weekly program fees, search for, and maintain employment, and follow all house rules.

I will be employed within 14 days of moving in. 

I understand that if I fail to meet these requirements and if I do not comply with the rules and conditions set forth by Grace House, I will be terminated from the program. Termination will require 24 hours to move out.  


I Text field attest that all the information that I have given is correct and give my consent to the verification of all the information that I have provided on this application. 
IText field understand that if I am approved to reside at Grace House, a nonrefundable deposit in the amount of $150 is due immediately to hold my room, 1st week's rent of $275 is due upon move-in. 

Resident Signature:

SignatureDate