MPR Resident Application

Resident Application

Please provide the following information:
Mountain Pass Recovery offers a safe, supportive recovery environment to men that:
- Are at least 18 years of age.
- Are medically and mentally stable at the time of move-in.
- Are 72-hours alcohol/drug free at the time of move-in.
- Identify as a person with substance abuse disorder.
- Have the desire to abstain from mind/mood altering substances.
- Are willing to participate in a program of recovery.
- Are committed to participating in weekly recovery workshops, recovery coaching and somatic recovery sessions.
Personal Information
Name*

First NameLast Name
Date of Birth:*
Cellular Number*
E-mail*
example@example.com
Prior Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Drug of Choice:*
Marital Status:
Spouse's Name:
Emergency Contact Name:*
Emergency Contact Relationship:*
Emergency Contact Number:*
If I become a resident, I grant MPR permission to contact my emergency contact in case of emergency.*

YesNo
Financial
Financial Transparency:

Mountain Pass Recovery reccomends a minimum stay of 90 days.

Policy:
- The monthly rate for stay at Mountain Pass Recovery is $-----.
- Each resident agree to pay their monthly rate on the first of the month.
- Residents who don't move in on the first of the month agree to pay a prorated monthly rate to transition to a first-of-the-month payment cylce.
- ACH is the preferred payment of MPR, but cashier's checks are also accepted.
Agreement:

I understand if I chose to submit an application, I am agreeing to pay my monthly invoice at move-in and promptly on the first of each month for the duration of my stay.
Medical
Do you have food allergies?*

YesNo
If yes, explain:
Do you have any physical health/medical conditions or disabilities?*

YesNo
If yes, explain:
Do you have a history of seizures?*

YesNo
Are you currently under the care of any of the following provider types?

Medical Doctor (PCP)PsychiatristPsychologistTherapistNutritionist
If yes, please provide the following information:
Care Provider Name
Care Provider Phone #
Can Mountain Pass Recovery release information to this person?
Yes    No
If yes, please provide the following information:
Care Provider Name
Care Provider Phone #
Can Mountain Pass Recovery release information to this person?
Yes    No
Mental Health
Do you have any mental health issues or diagnosis?*

YesNo
If yes, explain:
Do you have a history of self-harm?*

YesNo
If yes, explain:
Have you ever experienced any suicidal ideations, attempts, or received in-patient treatment for self harming behaviors?*

YesNo
If yes, explain:
Have you had any suicidal ideation in the past week?*

YesNo
Do you have an eating disorder or a body image disorder?*

YesNo
If yes, explain:
Medications
Are you currently using any prescription medications?*

YesNo
If yes, please provide:

Medication Name   Dosage

Medication Name    Dosage

Medication Name   Dosage

Medication Name   Dosage

Medication Name   Dosage

Medication Name   Dosage
Are you currently using any over-the-counter medications?*

YesNo
If yes, please provide:

Medication Name   Dosage

Medication Name    Dosage

Medication Name   Dosage

Medication Name   Dosage

Medication Name   Dosage

Medication Name   Dosage
Are you participating in or about to enter any drug replacement program?*

YesNo
If yes, select all applicable items:

Vivitrol and ReViaSubutexCampralBaclofenMethadoneSuboxoneAntabuseTopamaxSublocadeOther
If other, explain:
Treatment History
Are you currently in a treatment program?*

YesNo
If yes, please list:
Are you planning to attend an aftercare program or an intensive outpatient program?*

YesNo
If yes, please list and provide days/times of programming:
Recovery
Which recovery meetings do you attend?*

Adult Children of Alcoholics and Family DysfunctionAlcoholics AnonymousCelebrate RecoveryCocaine AnonymousGamblers AnonymousNarcotics AnonymousRecovery DharmaSmart RecoveryNoneOther
If other, explain:
When did you attend your first recovery meeting?
How many recovery meetings do you currently attend?
What is your sober/clean date?
Do you plan to attend 90 meetings in 90 days?

YesNo
Do you have a sponsor?

YesNo
Do you have a recovery coach?

YesNo
Courts & Criminal Justice
Are you currently involved in any legal proceedings or criminal justice issues?*

YesNo
If yes, explain:
Do you have a requirement for community service?*

YesNo
If yes, explain:
Do you have any pending sentencing or possible jail time upcoming?*

YesNo
If yes, explain:
Do you have any outstanding warrants?*

YesNo
If yes, explain:
Are you currently on probation or parole?*

YesNo
If yes, please provide the following information:
Probation Officer Name
Probation Officer Phone #
Can Mountain Pass Recovery release information to this person?
Yes    No
Are you required to register as a sex offender?*

YesNo
Employment
Are you currently employed?*

YesNo
If yes,
What is your current occupation?
What is your current work schedule?

If no,
Are you currently looking for employment?  Yes or No
Are you willing to make a volunteerism commitment?   Yes or No
Transportation
Do you have a valid driver's license?*

YesNo
Do you have a personal vehicle?*

YesNo
If yes to both, are you willing to be of service and help other residents get to meetings?

YesNo
Admissions
When would you like to move in?*
How long would you hope to stay at Mountain Pass Recovery?*

30 Days60 Days90 Days6 Months1 Year18 Months
Goals
What are your goals and expectations?*
How did you hear about our Recovery Residence? *
What would you like to accomplish while residing at Mountain Pass Recovery?*
Please enter any other information about yourself or your situation that you feel we should know
Date of Signature*

MonthDayYear
Date
Signature*

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Resident Application

Personal Information

Financial

Medical

Mental Health

Medications

Treatment History

Recovery

Courts & Criminal Justice

Employment

Transportation

Admissions

Goals