Recovery Program Intake Form

Valley Rescue Mission

Recovery Program Application


Name: Client first nameClient middle nameClient last nameText field Nickname: Client nickname

Address:Client Address Email: Text field Phone Number:Client phone

Birthdate:Client birthdate Age:Number field

Do you know or are you acquainted with anyone connected to Valley Rescue Mission?Text field

Why are you applying to a recovery Program at this time?Text field  What are your immediate needs?Text field  What are your present goals?Text field

List any Children and DOB:Text field

Emergency Contact:Text fieldText fieldText fieldText field

Do you have family in Muscogee County or the immediate area?Text field

What are your: strengths?Text field Weaknesses?Text field

Do you have a valid driver's license?CheckboxesYesCheckboxesNo

Referred By:Text field

Have you ever been arrested?Text field If so, what were your charges and the arrest date?Text field

Are you on Probation/Parole?CheckboxesYesCheckboxesNo   Probation/Parole Office/Officer Info:Probation

Are you a registered sex offender? CheckboxesYes CheckboxesNo    Were yiu convicted on or after July 1, 2008? CheckboxesYes CheckboxesNo

Do you smoke?Text field Are you willing to quit? Text field

Have you ever attempted suicide?Text field
If so, when?Text field

Do you have current suicidal thoughts?Text field
If so, when?Text field

Have you been hospitalized for emotional or nervous reasons?Text field

Have you every been in Therapy?Text field

If so, were medications prescribed?Text field Please list medications prescribed: Text field Are you currently on any medication?Text field If so, please list:Text field

Have you had any major surgeries in the last 5 years?CheckboxesYesCheckboxesNo        Do you have any upcoming major surgeries?Text field

Please provide the following information:

Family MembersMedicationTreatmentCenterHistoryEmploymentHistoryEducationHistorySoberLivingHistoryRecoveryHistoryLivingArrangementHistoryUA/BATherapist/ClinicianVaccinesMedical TestsClient sponsor

Drug of choice:Text field Age of firt use:Number field Longest period of sobriety:Number field

  Amount/How Often Date First Used Date Last Used
Cocaine/Crack Text field Date Date
Marijuana Text field Date Date
Heroin Text field Date Date
Alcohol Text field Date Date
Fentanyl Text field Date Date
Nicotine Text field Date Date
Prewcription Drugs Text field Date Date
Methamphetimines  Text field Date Date
Kratom Text field Date Date
Spice Text field Date Date
Other Text field Date Date
Please check if any of these apply to you:              
  Childhood Teen Adult Currently In therapy For Escaping None
Physical Abuse  Checkboxes Checkboxes Checkboxes Checkboxes Checkboxes Checkboxes Checkboxes
Emotional abuse Checkboxes Checkboxes Checkboxes Checkboxes Checkboxes Checkboxes Checkboxes
Sexual abuse Checkboxes Checkboxes Checkboxes Checkboxes Checkboxes Checkboxes Checkboxes
Financial Abuse Checkboxes Checkboxes Checkboxes Checkboxes Checkboxes Checkboxes Checkboxes
Victim of Human Trafficking Checkboxes Checkboxes Checkboxes Checkboxes Checkboxes Checkboxes

Checkboxes
Are you currently experiencing or diagnosed with: Yes No
Headaches Checkboxes Checkboxes
Difficuty Hearing Checkboxes Checkboxes
Vomiting Checkboxes Checkboxes
Hemmothoids Checkboxes Checkboxes
High Blood Pressure Checkboxes Checkboxes
Low Blood Pressure Checkboxes Checkboxes
Wear Prosthetic Checkboxes Checkboxes
Sores or Open Wounds Checkboxes Checkboxes
Dental Issues Checkboxes CheckboxesCheckboxes
Diarrhea Checkboxes Checkboxes
Palpitations Checkboxes Checkboxes
Numbness Checkboxes Checkboxes
Use Walking Device Checkboxes Checkboxes
Lomglasting Sores Checkboxes Checkboxes
Frequent Ear Aches Checkboxes Checkboxes
Heartburn or Gas Checkboxes Checkboxes
Constipation  Checkboxes Checkboxes
Shortness of Breath Checkboxes Checkboxes
Weakness Checkboxes Checkboxes
Fatigue Checkboxes Checkboxes
Joint Pain Checkboxes Checkboxes
Bruise Easily Checkboxes Checkboxes
Lice Checkboxes Checkboxes
Crabs Checkboxes Checkboxes
Painful Urination Checkboxes Checkboxes
Vision Issues Checkboxes Checkboxes
Hearing Aide Checkboxes Checkboxes
Dizziness Checkboxes Checkboxes
Abdominal Pain  Checkboxes Checkboxes
Cramping Checkboxes Checkboxes
Chest Pain Checkboxes Checkboxes
Neck Pain Checkboxes Checkboxes
Shoulder Pain Checkboxes Checkboxes
Back Pain Checkboxes Checkboxes
Skin Irratation  Checkboxes Checkboxes
Current Injury Checkboxes Checkboxes
Frequent Urnation  Checkboxes Checkboxes
Unusual Discharge Checkboxes Checkboxes
Withdraw Checkboxes Checkboxes
Blackouts Checkboxes Checkboxes
Mumps Checkboxes Checkboxes
Kidnet Problems Checkboxes Checkboxes
Cancer Checkboxes Checkboxes
Mental Illness Checkboxes Checkboxes
Emotional Abuse Checkboxes Checkboxes
Herpes Checkboxes Checkboxes
Hallucinations Checkboxes Checkboxes
Rhematic Fever Checkboxes Checkboxes
Liver Problems Checkboxes Checkboxes
Hapatitis Checkboxes Checkboxes
Heart Disease Checkboxes Checkboxes
Physical Abuse Checkboxes CheckboxesCheckboxes
Gonorrhea Checkboxes Checkboxes
Delirium  Tremens (DT's) Checkboxes Checkboxes
Jaundice Checkboxes Checkboxes
Arthiritis Checkboxes Checkboxes
Stroke Checkboxes Checkboxes
TB Checkboxes Checkboxes
Syphillis Checkboxes Checkboxes
Seizures Checkboxes Checkboxes
Typhoid Checkboxes Checkboxes
Ulcers Checkboxes Checkboxes
Diabetes Checkboxes Checkboxes
Tuberculosis Checkboxes Checkboxes
Sexual Abuse Checkboxes Checkboxes
HIV Checkboxes Checkboxes
AIDS Checkboxes Checkboxes

What is the highest level of education completed?Text field
Are you a Veteran?Text field
Are you employed?Text field
Last residence.Text field
Ever received housing assistance?Text field
Do you owe the Housing Authority money?Text field
Are you presently homeless?Text field

Are you currently receiving Medicare/Medicaid, disability or other Government aid?Text field
Are you on food stamps/EBT?Text field

If selected for residence in this program, is there anything that we should know about you that would hinder your ability to sweep, mop, lift, mow, or do normal household chores?Text field
Please give a little background about yourself and why you feel this is the right program for you.Paragraph
NOTE: This center is not a medical or psychiatric facility: therefore, prospective clients must be medically, as well as, psychiatrically cleared prior to admission. The requested medical information within this application for consideration of admission form is vitally important and is required before a decision can rendered as to the appropriateness of our facility for prospective clients. If mental health evaluation / documentation is requested, that also must be received before a final decision can be made regarding placement in the Recovery Program. If, within 30 days of admission, it is noted that the client is inappropriate due to medical or psychiatric reasons about which we were uninformed prior, this facility reserves the right to refer the client to another facility or back to the referring agency.

 

Siignature:Signature  Date:Date