Fresh Wind Recovery Application

Fresh Wind Recovery Ministry

Pre-Application Form
Please note, the following survey collects sensitive data and PII (Personally Identifiable

Information).
Personal Information:
Please Provide Your Full Name (i.e. first, middle and last name)*

First NameMiddle NameLast Name
Preferred Name
What do you prefer to be called?
Client Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Sex Assigned at Birth

MaleFemale
Gender identity?

FemaleMaleTransgenderNon-BinaryOther
Sexual Orientation?

HeterosexualGayLesbianBisexualQueerOther
Race?

American Indian, Alaska Native, or IndigenousEast AsianSouth AsianSoutheast AsianBlack or African AmericanHispanic, Latino, Latina, or LatineNative Hawaiian or Other Pacific IslanderWhiteOther (Please Specify)
Race, Cont.
If Other, please specify here.
Primary Contact Number ?*
If you are currently residing within a facility(jail, prison, hospital, detox unit), please indicate a contact person/case manager that we maycontact. If you are incarcerated, what is your release date, court date, or sentencing date?
Alternative Contact Person & Number
Emergency Contact:*
for a family member, case manager, community supervision officer, etc.
Emergency Phone Number:*
Do you have a Driver’s License and/or ID?

State IDDriver’s LicenseSocial Security CardPassportNone
If no, do you have a birth certificate

YesNo
Living Situation:
Are you currently incarcerated*

YesNo
If so, what is the name of the institution
If no, you can skip this question.
Release Date/Court Date/Sentencing Date:
What is your living situation?*

Permanent housingTemporaryhousingUnhousedOther
Who were you living with before entering the program?*

SpousePartnerFriendParentLacked Permanent HousingOther
If you have a permanent address, please provide here

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you currently employed?

YesNo
If "Yes" then where?
Business Name
Do you currently have any form of income?

YesNo
Please select your source of income from the following:

Temporary Assistance for Needy Families (TANF)Supplemental Nutrition Assistance Program (SNAP) - Food StampsMedicaidMedicareSocial Security Income (SSI)Social Security Disability Income (SSDI)Unemployment IncomeChild SupportOther
Please identify the amount of income.
If you selected 'Other,' please identify the source of:
Family & Childcare:
Are you:*

SingleMarriedDivorcedWidowedPartnerSeparated
Do you have any children?

YesNo
Please list the gender and age of each child:
Are you pregnant?

YesNoNot Applicable (N/A)
Do you have an active Child Protective Services case with DFCS?

YesNo
Do you have custody of your children?*

YesNo
Are you seeking reunification with your children?*

YesNoNot Applicable
What are your childcare plans while in the program?*

Family member has temporary custodyChildren are in Mother’s care.Child is no longer a minorFoster careOther
Substance Use & Treatment History:
What was the first age you used alcohol or other drugs?

Under 1313-15 years old16-18 years old18-20 years oldOver 21 years old
What substances do you use?

AlcoholMethamphetamineHeroinPrescription Medication/PillsMarijuanaCocaineKratomOther
What methods have you used to take your substance(s) of choice?

DrinkingSmoking (pipe,etc.)Swallow (as pill)SnortInjection/Shoot Up (Intravenous Use - IV)Inhale/HuffOral Ingestion(except swallowing)Other
What was your last date of use and how much?
Do you require detoxification or hospitalization?*

YesNo
Have you previously been in treatment?

YesNo
If yes, how many times and when/where?
Did you leave any treatment Against Medical Advice (AMA)?
Medical & Mental Health History:
Do you currently have any medical conditions?*

YesNo
If Yes, please describe:
Do you have any physical or mental health disabilities that prevent you from working?

YesNo
If yes, please specify (with diagnosis if diagnosis):
Are you currently prescribed any of the following medications?

SuboxoneMethadoneSubutexBuprenorphineNaltrexoneVivitrol
List any other current medications (Mandatory):
Who is your current physician/doctor?
If you do not currently have or are seeing a doctor, please specify
Do you have any allergies? (Food, bugs, medication, etc.)
If yes, please list all allegeries
Do you currently need medical attention?

YesNo
If yes, please describe your current needs:
Do you have any long-term medical conditions (e.g., diabetes, high blood pressure, epilepsy)?

YesNo
If yes, please list here:
Do you have medical insurance?*

YesNo
If yes, please list provider
Legal & Community Supervision:
Do you have any past or pending legal issues?

YesNo
Please describe the charge, date, and sentence.
Example: "Arrested in June 2015 for drug possession inColumbia County, currently participating in drug court services", etc.
Are you under community supervision (probation or parole)?

YesNo
If yes, list your community supervision officer’s contact information:
Name, Phone Number, etc.
Does your officer know you are seeking treatment?

YesNo
How often are you required to report?
Do you have a public defender or private attorney?

YesNo
If yes, list their contact information:
Are you required to register as a sex offender?*

YesNo
If yes, provide details:
Military Service:
Have you ever served in the military?*

YesNo
Has an immediate family member served in the military?*

YesNo
Agreement & Authorization:
Why are you seeking treatment at Fresh Wind?
Social Security Number*
(To be provided via call for security reasons)
I give permission to Fresh Wind Recovery to run a criminal background check.*

I agree
I hereby declare that all the information I have given in this application is true. I understand that any false information will be grounds for non-admission to or dismissal from the Fresh Wind Recovery program. I also understand that submitting this application does NOT guarantee entrance into the Fresh Wind residential program.
Signature
Initials to Agree to Terms Above:*
Should be Empty:

Fresh Wind Recovery Ministry

Personal Information:

Living Situation:

Family & Childcare:

Substance Use & Treatment History:

Medical & Mental Health History:

Legal & Community Supervision:

Military Service:

Agreement & Authorization: