Recovery Housing Bed Request

Recovery Housing Bed Request
Relationship*

I am filling this form out for MYSELFI am filling this form out on behalf of SOMEONE ELSE
What is your relationship to the person needing the bed?*
How did you hear about us?*
What is your available move-in date?*

MonthDayYear
Date
Name*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Best Phone Number to Contact you:*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Previous Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What County are you from?*
Gender*
Marital Satus*
Insurance Status*
SSN:*
Name of Insurance Provider (Anthem, BlueCross, Buckeye, Caresource, etc.)*
Please List Insurance Provider*
Do you have a photo ID?*

YesNo
Are you able to walk stairs?*

YesNo
Are you currently employed?*

YesNo
Employment Status*

Full TimePart TimePRN/Seasonal
Recovery History
Main substance used:*
Sobriety Date:*

MonthDayYear
Date
Did you undergo medical detox?*

YesNo
Detox Location:*
Detox Admission Date:*

MonthDayYear
Date
Are you currently in residential treatment?*

YesNo
CURRENT Location:*
Treatment Admission Date:*

MonthDayYear
Date
Are we able to speak to your current case manager or counselor?*

YesNo
Case Manager Name:*
Case Manager Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Did you previously complete in-patient treatment?*

YesNo
PREVIOUS Treatment Center Name:*
PREVIOUS Treatment Admission Date:*

MonthDayYear
Date
Do you currently have out-patient services?*

YesNo
Which out-patient services are you involved in?*

Peer Support/Recovery CoachIOP/PHPCounselingPsychiatry
Who provides out-patient services? (i.e. Ohio Guidestone, Alternative Paths, LCADA)*
Additional recovery services (Peer Support & recovery planning) and a Drug/Alcohol Mental Health Assessment are required for residency. A list of in-county agencies that provide peer support and other out-patient services will be provided to you during your Hope Recovery Housing phone interview.

We are glad to assist you in the process of obtaining these out-patient services at your request, which may be able to start prior to living at Hope Recovery Community - Recovery Housing.
Consent for Out-Patient Services*

I consent to allow Hope Recovery Community to use the above information to schedule a Drug/Alcohol Mental Health Assessment and recovery services at my requestI DO NOT consent for Hope Recovery Community to use my information for a Drug/Alcohol/Mental Health Assessment
Have you ever or do you currently live in recovery housing/sober living?*

YesNo
Previous Recovery Housing (add all)*
Please list medical history: *
Do you take medications?*

YesNo
Medication List*
Are you on any MAT substances?*

SuboxoneSublocadeVivitrolOtherNone
Criminal Justice Involement
Please note, failure to disclose full criminal history or pending warrants will result in termination from the recovery housing program.
Are you a registered sex offender?*

YesNo
Do you have any outstanding warrants?*

YesNo
Please list active warrants and location:*
Do you have any felony convictions?*

YesNo
Please list all felony convictions:*
Are you on probation?*

YesNo
Probation officer name:*
Probation county:*
Do you have any pending jail time or upcoming sentencing?*

YesNo
Please explain upcoming sentencing/jail time:*
Can you pass a drug/alcohol test?*

YesNo
General Notes:
AUTHORIZATION FOR BACKGROUND CHECK
By signing below, I authorize Hope Recovery Community to conduct a background check at their discretion for any reason that they deem said background check necessary or helpful to their conducting business.

By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.

Once your form is submitted we will call you to conduct a phone interview.
Signature*
Should be Empty:

Recovery Housing Bed Request

Recovery History

Criminal Justice Involement