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?
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?
Are you engaging in behavioral health services?
Name of Behavioral Health agency.
Recovery Coach name and contact number.
Does The Well have permission to coordinate with your behavioral health agency?
List phychiatric medications that you are perscribed
Are you med-compliant
Do you have a history with suicide?
Have you ever tried to take your own life?
In the past week, have you been having thoughts about taking your own life?
Do you have any medical diagnosis? Add multiple by clicking in the box and selecting different optionsClient health problems
Have you had any hospitalizations in the last 90-days?
Name of facility
Reason for admit
Name and contact number to social worker or recovery coach
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?
Are you at risk for exposure to any communicable diseases, or have you been in contact with someone who has?DropdownAre you experiencing shortness of breath, coughing, fever, or other symptoms of Coronavirus and/or a flu?DropdownHave you tested positive for COVID-19 in the past 10-days?DropdownAre you currently awaiting results from a COVID-19 test?Dropdown
The Well requires that a Release of Information be completed for the purpose of coordinating with your probation officer.
Are you on probation or parole?
Have you ever been incarcerated? If so, what were the charges?
Name and contact number of probation/parole officer.
Does The Well have permission to communicate with your probation/parole officer?
The monthly fee is $700.
How will you pay your fees?
Do you currently have an income?DropdownAre you able to work?DropdownDo you have any barriers to gaining employment?DropdownAre you currently employed?DropdownWhat is your current occupation?