Elevate New Member Application

Elevate Member Application
Member Name*

First NameLast Name
Nickname
Member Email*
example@example.com
Member Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth*

MonthDayYear
Date
How did you hear about Elevate?*
What is your highest level of education? *
Do you have any means of transportation? *
Demographics
What is your ethnicity? *
Do any of the following apply to you?

VeteranDisabled VeteranCollecting DisabilityNone apply to mePreviously Homeless
Employment History
Employment Status *
Date of most recent employment | START DATE *

MonthDayYear
Date
END DATE - Use today's date if you are CURRENTLY employed *

MonthDayYear
Date
Current Employer
We will not contact your employer without previous written consent via a release of information
Employer Contact

First NameLast Name
Employer Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Employment History, Notes and Comments*
All members are required to maintain full-time employment, volunteering or treatment plans >= 40 hours per week
Current average monthly income*
Insurance Information
Do you have Health Insurance? *
Insurance Provider*
Policy Number, Medicaid Number or Social Security Number*
Medical History
How you ever been diagnosed with any of the following conditions?*

Anxiety DisordersDepressionBipolar DisorderPost-Traumatic Stress Disorder (PTSD)SchizophreniaEating DisordersDisruptive behavior and dis-social disordersNeurodevelopmental disordersSuicidal ideationDoes not apply to me
Are you currently taking any medications? *
Have you ever been prescribed or are you currently taking any anti-psychotic medications? *
Please list all medications you are currently prescribed
Have you been diagnosed with any of the following infectious diseases?*

No / Does not apply to meHIV/AIDSHepatitis BHepatitis CChronic measles
Disclosure - It is important to note this is a NON-Clinical recovery community. We do not staff medical professionals, psychologists, nurses, or doctors in our facilities. We do not prescribe or distribute any medications and all medication management is your sole responsibility. In most cases, we can provide referrals to professional clinical resources upon request.
Recovery History

Please provide additional details about your recovery journey
When is your sobriety date ? (Date of last use)*

MonthDayYear
Date
How many times in the last five years have you attempted to stay sober? *
What is your longest period of sobriety? *
Enter a number of days or years
What are your substances of choice? (check all that apply)*

AlcoholMarijuanaCocaineMethamphetamineMDMA (Ecstasy/Molly)Opioids (Heroin, Oxycodone, Hydocodone, Fentanyl)Hallucinogens (LSD, Mushrooms, Mescaline, PCP)Sedatives (Xanax, Ketamine, Ambien)
How long have you been using these substances? *
What does SOBRIETY mean to you? *
What recovery programs have you already tried?*

DetoxRehabSober LivingIOP (Intensive outpatient)PHP (Partial hospitalization program)None
Are you currently in a treatment facility? *
Current Facility type*

HospitalTreatment CenterCity/County DetoxCity/County JailPrisonPsychiatric WardSober Living Community
Treatment Center / Facility name *
Case Manager

First NameLast Name
Case Manager - Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Discharge date

MonthDayYear
Date
Criminal Record
Do you have a criminal record? *
Have you been convicted of any of the following crimes (Select ALL that apply)*

Driving while intoxicated / under the influenceSex CrimesViolent CrimesHate CrimesCrimes against childrenTheftArsonMurder / Attempted murderNone - Does not apply
Are there any charges PENDING against you? *
Please provide details of your previous convictions or any charges pending against you:
Do you currently have any warrants for your arrest in Colorado or other states?*

NoYes - Colorado WarrantYes - Warrant in another statePossible warrant but unsure of the current status
Are you currently on parole, probation or other corrections supervision?*
Probation / Parole / Case officer name
Case Officer Email
example@example.com
Case Officer Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Probation / Parole - Completion Date

MonthDayYear
Date
Terms of your parole and probation?
Case management is included in our program and we work on your behalf as a advocate with your supervision requirements in order to ensure your recovery progress is known and celebrated
Background check disclaimer - Elevate Recovery Homes is required to conduct a full background check on all applicants in order to ensure the safety of all program participants. That being said, we meet all clients where they are today and use the background information as a basis and starting point of your journey, not a bias of discrimination.
Support System & Emergency Contacts

Please tell us about your support system. Who is in your corner that will be aiding you with your recovery plan in and outside of the peer support and program support you will receive through Elevate Recovery Homes ?
Please provide some insight into your existing support system including family*
Emergency Contact
Emergency Contact Name*

First NameLast Name
Emergency Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Email*
example@example.com
Relationship*
Disclaimer - In order for us to provide ANY information to this party or any parties in the future you will need to sign a formal RELEASE OF INFORMATION form before we will disclose any details about your involvement in our program.
Program Participation
At Elevate Recovery Homes we offer residential recovery communities in;

Arvada | Jay House

Centennial | Penrose House / Clarkson House

Denver | Twin Lakes House

Englewood | Tufts House

Northglenn | Sully House

Westminster | Winona House

All communities follow our "Elevation Plan" which requires weekly participation in various programs including but not limited to weekly house meetings
Which of our locations are you interested in?*

ArvadaCentennialDenverEnglewoodNorthglennWestminster
Desired move in date? *

MonthDayYear
Date
What is your estimated length of stay with us ? *
We suggest a minimum of 90 days in the program to extract the maximum value in your recovery
If accepted, why do you feel Elevate is the best program for you in your recovery? *
How do you plan to stay active in your recovery OUTSIDE of our program? *
To verify your identity we need a copy of a photo id.

Drivers LicenseIdentification CardDOC ID CardSchool ID Card
Upload Photo ID

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NEXT STEPS

Application review process
At Elevate Recovery Homes, we value your privacy and believe in the importance of obtaining your explicit consent before sending messages. We are requesting your consent for the following purposes:
- Responding to inquiries and prospective applicant submissions via text messages and email.
- Confirming and sending reminders for scheduled events that you sign up for.
By providing your consent, you are allowing us to use text messages, emails and other means of electronic communications for these specific purposes. Your information will be treated with the utmost confidentiality. You can withdraw your consent at any time. Please note that standard message and data rates may apply.
To consent, please check the box below.*

I consent to receiving text messages and emails
Upon receipt of your completed application, you will receive a phone call or email from our admissions staff within 24-48 hours (likely the same day) either approving your application for placement or referring you to an alternative level of care.

If you are UNABLE to receive emails, please list an alternate email address below to receive any status updates on your application.
Alternate / temporary email address
(Used for case managers or other temporary contacts as needed) example@example.com
What is the best number to reach you at for your interview call if your application is approved?
Please enter a valid phone number.Format: (000) 000-0000.
Is there anything else you'd like us to know about you when considering your application? *
Congratulations on taking the next step in your recovery journey. We are honored to have the opportunity to work with you and we will be in contact soon to discuss the next steps.

Sincerely,

Elevate Recovery Homes
Placement Status
Placement Location
Room Type
Admission Date / Time

MonthDayYear
Date
Hour MinutesAM/PM Option
Payment Type
Suicidal Ideation
1) Have you wished you were dead or wished you could go to sleep and not wake up?
2) Have you actually had any thoughts about killing yourself? (If YES, go to questions 3, 4, 5, and 6. If NO, go directly to question 6)
3) Have you thought about how you might do this?
4) Have you had any intention of acting on these thoughts of killing yourself, as opposed to you have the thoughts but you definitely would not act on them? (Yes = High Risk)
5) Have you started to work out or worked out the details of how to kill yourself? (Yes = High Risk)
6) Have you done anything, started to do anythiong, or prepared to do anything to end your life? (Yes = High Risk)
Psychosis (Current)
SO
Arson
Initial payment amount
Second payment amount
Placement Conditions
Placement STAFF
Should be Empty:

Elevate Member Application

Demographics

Employment History

Insurance Information

Medical History

Recovery History

Criminal Record

Support System & Emergency Contacts

Emergency Contact

Program Participation

NEXT STEPS

Suicidal Ideation