John Ryan's House @ JADE Wellness Center

John Ryan's House @ JADE Wellness Center

Referral For Residency at John Ryan's House must present with a substance use disorder. Residency limited to 150-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. Inquiring residents with Megan's Law violations will not be approved for residency. Inquiry must be residence of Allegheny County and over the age of 18.
I understand that the desired admission date must be 120 days from submission date or this form will not be valid. You must resubmit the form within 120 days of your desired residency.

YesNo
I understand that an open bed must be assigned no greater than 7 days in advance.

YesNo
The following items are a requirement to maintain residency at John Ryan's House
- Attend and comply with licensed Drug and Alcohol treatment at the recommended level of care.
- Attend a 1:1 with a house staff (CRS or care manager) once per week.
- Provide two urine drug screens to house staff per week when requested.
- Attend the Monday night house meeting from 8:30PM to 9:30PM.
- Attend 3 self-help groups per week.
- Be home by curfew (10:30PM on weekdays and 11:30PM on weeknights).
- Be out of your room by wake up call (9AM Monday through Saturday and 11AM Sun).
- Keep room clean and comply with room checks.
- Complete assigned chore duty daily.
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:

MonthDayYear
Date
Desired Admission Date:

MonthDayYear
Request must be 72 hours before desired admission date.
Residents Name:

First NameLast Name
Date of Birth

MonthDayYear
Date
Social Security Number:
Phone Number
Please enter a valid phone number.
Email
example@example.com
Gender Identity:
Ethnicity:

African AmericanAsianCaucasianHispanic/LatinoOther
Living Arrangement:

UnhousedIncarcerationInpatient D&ADetoxificationHospitalizationInpatient Mental HealthIndependent LivingOther
Current or most recent address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you a current resident of Allegheny County? (Do you have Allegheny County Address on your I.D.?)*

YesNo
Insurance/Funding
If Other Funding Source, Specify:
Member ID:
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 NameLast 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

CityState / 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?

YesNo
LOC Agency Name:
LOC Date Completed

MonthDayYear
Date
Level of Care Assessment Recommendation:
List substances used in the past 90 days.
List Substance Used
Date of last use

MonthDayYear
Date
Add another:

YesNo
List Substance Used
Date of last use

MonthDayYear
Date
Add another:

YesNo
List Substance Used:
Date of Last Use:

MonthDayYear
Date
Please list if you have been in any of the following Licensed Recovery Houses in the past 365 days.

Heuer HouseEast End Cooperative Ministry (EECM)Other Recovery HouseI have not been in a licensed recovery house in the past year.
Admission date at Heuer House

MonthDayYear
Please list approximate date you were admitted into Heuer House
End of residency date Heuer House

MonthDayYear
Please list approximate date you ended residency with Heuer House
Admission date at EECM

MonthDayYear
Please list approximate date you were admitted into EECM
End of residency date EECM

MonthDayYear
Please list approximate date you ended residency with EECM
Other Recovery House:
Please list the name of other recovery house you were a resident at:
Admission date.

MonthDayYear
Please list approximate date you were admitted.
End of residency date.

MonthDayYear
Please list approximate date you ended residency.
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.
Signature

Powered by Jotform SignClear
Documents
If referring from a treatment provider, you must provide one of the following via email or upload below:

Level of Care AssessmentDischarge SummaryDischarge ASAM
Upload or email any files including Consents, ASAM, LOCA, Discharge Summary

All Jotforms are HIPAA protected
Cancelof
John Ryan's House takes calls on Mondays and Friday from 8:30AM to 5PM to discuss inquiry list and bed availability.

Please feel free to reach out to the following number if you have questions on bed availability:
Contact Autumn at:
Phone: 412-440-7478
Email: Autumn@myjadewellness.com

*Please note: Our admission process reviews house inquiries considering multiple facets, includig referral date and prioirty population. Prioirty populations includes IVDU, unhoused, and verbalized willingness to participate with house rules and regulations. Referral to the program does not gaurantee residency.
Should be Empty:

John Ryan's House @ JADE Wellness Center

Income Source

Emergency Contact

Referral Source and Level of care Assessment

List substances used in the past 90 days.

Medications

Documents