Application for Residency – Positive Recovery Resources

Name*

First Last

Email*

Phone*

Referred*

Date of Birth*

Current Legal Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Projected Intake

Substance Abuse History

When did you last abuse a substance?*

What was the last substance you abused?*

Substance Use History*

Alcohol Use Frequency*

Amphetamines Use Frequency*

Barbiturates Use Frequency*

Crack/Cocaine Use Frequency*

Hallucinogens Use Frequency*

Heroin Use Frequency*

K2/Spice Use Frequency*

Marijuana Use Frequency*

Methamphetamine Use Frequency*

Oxys/Roxys Use Frequency*

Percocets Use Frequency*

Xanax Use Frequency*

Klonopin Use Frequency*

Other Use Frequency*

What Substance is "Other"*

Last treatment center you attended?*

Last detox center you attended?*

Last recovery residence you resided in?*

Previous rent cost at last recovery residence?*

Before leaving previous recovery residence was all rent satisfied?*

Yes
No

What type of meetings do you prefer?*

Drug Abuse Anonymous (DAA)
Celebrate Recovery
Narcotics Anonymous (NA)
Cocaine Anonymous (CA)
Alcoholics Anonymous (AA)
Other

Do you have a home group?*

Yes
No

Do you have a sponsor?*

Yes
No

Sponsor's Name

Sponsor's Phone Number

What is your current level of cravings for your substance of choice?*

1=None, 10=Currently Using

Do you currently feel like harming yourself or others?*

Yes
No

Have you ever been diagnosed with a prior mental health diagnosis?*

Health Information

Do you have any medical problems?*

Were you tested for HIV/AIDS or STDs within the last 6 months?*

Yes
No

Do you have a personal physician and/or psychiatrist?*

Yes
No

Do you have any allergies?*

Yes
No

Are you currently on any medications?*

Yes
No

List of medications you are currently taking

How do you plan on paying for your medication?*

Do you currently have health insurance?*

Yes
No

Health Insurance Information

Please provide an attached version of your health insurance card or health insurance information below.

Attached copy of health insurance card

Subscriber First Name*

Subscriber Last Name*

Subscriber DOB*

Relationship to Subscriber*

Insurance Company*

Insurance Phone*

Payer ID*

Group ID*

ID Number*

Do you have family or loved ones that would assist you in case of an emergency?*

Yes
No

Employment & Transportation

Do you currently have a job?*

Yes
No

If yes where?

Do you currently have a reliable form of transportation?*

Yes
No

If Yes, What type?

Car
Bicycle
Scooter
Skateboard
Other

How much do you currently make?

Legal

Do you currently have any legal issues?*

Yes
No

What are your current legal issues?

Are you currently on probation?*

Yes
No

Have you ever been convicted as a sex offender?*

Yes
No

Emergency Contact

Name*

First Last

Phone Number*

Email

Relationship*