The Well is a Christ-centered faith-based recovery home. There is a Bible Study in the house on Saturdays from 12-1 pm. Guest at The Well are required to attend. Are you willing and able to attend?
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General
First name
Client first name
Last name
Client last name
Date of Birth
Client birthdate
Email address
Client email
Phone number
Client phone
Gender
Client gender
Marital status
Client marital statusAre you working towards reunification with your child/children?
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Religious preference?
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List two emergency contacts
Contact
Mental Health & Substance Abuse History
The Well requires that a Release of Information be completed for the purpose of coordinating with your behavioral health agency.
Do you have any mental health diagnosis?
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Are you engaging in behavioral health services?
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Name of Behavioral Health agency.
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Recovery Coach name and contact number.
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Does The Well have permission to coordinate with your behavioral health agency?
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List phychiatric medications that you are perscribed
Medication
Are you med-compliant
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Do you have a history with suicide?
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Have you ever tried to take your own life?
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In the past week, have you been having thoughts about taking your own life?
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What were the last substances that you used and when?
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What is your substance(s) of choice? Add multiple by clicking in the box and selecting different options
Client substances of choice
Do you engage in medical assisted treatment services?
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Are you currently in a residential treatment program?
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Name of treatment facility
TreatmentCenterHistory
Medical History
Do you have any medical diagnosis? Add multiple by clicking in the box and selecting different options
Client health problems
Medication
Have you had any hospitalizations in the last 90-days?
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Name of facility
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Dates admitted
Date
Reason for admit
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Name and contact number to social worker or recovery coach
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Activities of daily living are activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating.
Are you able to complete Activities of Daily Living (ADL’s) independently?
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Are you at risk for exposure to any communicable diseases, or have you been in contact with someone who has?
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Are you experiencing shortness of breath, coughing, fever, or other symptoms of Coronavirus and/or a flu?
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Have you tested positive for COVID-19 in the past 10-days?
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Are you currently awaiting results from a COVID-19 test?
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The Well requires that a Release of Information be completed for the purpose of coordinating with your probation officer.
Name and contact number of probation/parole officer.
The monthly fee is $700.
Income and Employment
Do you currently have an income?
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Are you able to work?
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Do you have any barriers to gaining employment?
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Are you currently employed?
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What is your current occupation?
EmploymentHistory
Admissions
When would you like to move?
Date
What is the estimated length of stay?
Client estimated length of stay