John Ryan's House @ JADE Wellness Center
Referral For Residency at John Ryan's House. Residency limited to 90 day duration. Individuals seeking residency must not present at risk of acute withdrawal or have any indication of illicit drug use at time of admission. Inquiry must be residence of Allegheny County and over the age of 18.
Provider/community referral or resident referral?
I am an individual seeking residency to John Ryan's House for myself.
I am referring an individual for residency to John Ryan's House.
Date of Referral:
-
Month
-
Day
Year
Date
Desired Admission Date:
-
Month
-
Day
Year
Request must be 72 hours before desired admission date.
Residents Name:
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Social Security Number:
Phone Number
Please enter a valid phone number.
Email
example@example.com
Gender Identity:
Ethnicity:
African American
Asian
Caucasian
Hispanic/Latino
Other
Living Arrangement:
Unhoused
Incarceration
Inpatient D&A
Detoxification
Hospitalization
Inpatient Mental Health
Independent Living
Other
Current or most recent address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you a current resident of Allegheny County? (Do you have Allegheny County Address on your I.D.?)
*
Yes
No
Specify current living arrangement details: (include last place of residency, duration, living environment, location)
Income Source
Source of Income:
Monthly Amount:
Emergency Contact
Emergency Contact Name
First Name
Last Name
Emergency Contact Relationship:
Emergency Contact Phone Number
Please enter a valid phone number.
Referral Source and Level of care Assessment
Agency:
Contact Person:
Referral Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Description of Substance Use Disorder and Mental Health Diagnosis:
Was a Level of Care Assessment completed within the past 6 months?
Yes
No
LOC Agency Name:
LOC Date Completed
-
Month
-
Day
Year
Date
Level of Care Assessment Recommendation:
List substances used in the past 90 days.
List Substance Used
Date of last use
-
Month
-
Day
Year
Date
Add another:
Yes
No
List Substance Used
Date of last use
-
Month
-
Day
Year
Date
Add another:
Yes
No
List Substance Used:
Date of Last Use:
-
Month
-
Day
Year
Date
Medications
List Current Presription and Over the counter medications.
Prescription Medications
Please list medication name, dosage, frequency of dose and prescriber.
Over the counter & supplements
Please list any over the counter medications or supplements you are taking.
Documents
Upload any files including Consents, ASAM, LOCA
Browse Files
Drag and drop files here
Choose a file
All Jotforms are HIPAA protected
Cancel
of
Signature
Continue
Continue
Should be Empty: