SOR Residential Treatment Application

Stewards of Recovery

Adult Residential Treatment Application
Employment Status*

Full TimePart TimeUnemployedDisability
Employer*
Do you have a valid drivers license?*

YesNo
Do you own a vehicle?*

YesNo
Make/Model*
Legal
Are you currently on probation or parole?*

YesNo
Probation Officer Information
Do you have any pending charges?

YesNo
Have you ever been charged for a violent crime or crime of sexual nature?*

YesNo
Please explain
Funding Source (Medicaid, state funding, insurance, or ect.)
Substance Use
Please provide a brief history of your substance use in your own words. When you started, when you used, how much for how long:*
Prior substance abuse treatment?*

YesNo
Do you have any current medical conditions?*

YesNo
Are you currently taking prescribed medications?*

YesNo
Do you have diabetes?*

YesNo
Do you take insulin?

YesNo
Are you pregnant?*

YesNo
Are you receiving Prenatal Care?

YesNo
Expected Due Date:
Do you have Children?*

YesNo
Do you have an open case with Child Protection Services?

YesNo
Name of CPS Worker:
What was the original cause for your current CPS case:
Please attach all Assesments/Screenings/Notes/ROI
Browse Files

Cancelof
{name}
Signature*

Clear
Date and Time

Release of Information
CLIENT NAME

First NameLast Name
By signing below, I, hereby authorize Stewards of Recovery to release and/or obtain information with respect to any medical, psychiatric, drug and/or alcohol related conditions obtained during the course of diagnosis and/or treatment to/from the individual(s) or healthcare providers listed below. The type of information authorized for disclosure includes, but may not be limited to, that which is indicated below. I understand that my signature below will not have affect on the ability or inability to determine, limit or restrict my treatment.

I understand that any information released with this consent in regards to treatment, payment and/or healthcare operations may be re-disclosed by the receiving service provider under this initial consent, if and only if, it pertains to my treatment, payment and/or healthcare operations.

I understand that I have the right to limit or restrict the re-disclosure of my information by other service providers in regards to my treatment, payment and/or healthcare operations
Agency/Prior Treatment Facility/Individual
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Fax

Area CodePhone Number
Email
example@example.com
Signature

Clear
Should be Empty: