Intake Application
Journeys Recovery Home
Name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Preferred Method of Contact
Phone Call
Text
Email
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Name
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Health Card #
Health Card Expiry Date
Do you have any chronic illnesses, physical disabilities or medical conditions? (e.g., diabetes, hypertension)
*
Yes
No
If yes, please specify
Are you able to go up and down the stairs?
*
Yes
No
Not without Difficulty
Have you had any surgeries or hospitalizations in the past?
*
Yes
No
If yes, please provide details
Are you currently taking any medications?
*
Yes
No
If yes, please list the name of medication, dosage and reason for use
Do you have any allergies? (e.g., food, medication, environmental)
*
Yes
No
If yes, please specify
Do you smoke?
*
Yes
No
If yes, how many cigarettes per day
Do you consume alcohol?
*
Yes
No
If yes, how often and how much
Do you use recreational drugs?
*
Yes
No
If yes, please specify what drug(s)
How often do you use drugs or alcohol?
*
Daily
Several times a week
Once a week
Rarely
Never
Other
Are you on Methadone or Suboxone?
*
No
Methadone
Suboxone
If yes, Please list dosage per day
*Note: We do accept patients on Methadone or Suboxone at Journeys Recovery Home. However, we will require you to slowly wean off during your 6 months stay. This will be monitored closely by staff and your doctor.*
Are you currently experiencing any of the following symptoms? (Check all that apply)
*
Acute or Chronic Psychosis
Eating Disorder
Chronic Pain
Self-harm
Anxiety
Depression
Suicidal Thoughts
Thoughts of Harming Others
Abuse
Homelessness
Loneliness
Angry Outbursts
None of the above
Have you ever been diagnosed with any of the following? (Check all that apply)
*
Anxiety Disorder
Depression
Bipolar Disorder
Borderline Personality Disorder
PTSD
Dementia
Cognitive Disorder
Narcissistic Personality Disorder
Obsessive Compulsive Disorder
Dissociation
Eating Disorder
Autism
None of the above
Other
If yes, when did you receive this diagnosis?
How would you describe your current mental health status?
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Do you have any current or on-going legal issues? (Please select all that apply)
*
No
Probation
On Bail
Current Charges
Upcoming Court Dates
Sexual Charges
Active Warrant
Currently Incarcerated
House Arrest
Peace Bond
No-Contact Order
Restraining Orders
If yes, please give details on any current charges and orders. This includes dates for court, Peace Order/No Contact/Restraining Order information as well as any Bail conditions.
Please select all that apply
*
History of Fire Setting
History of Self-harm
History of Suicide Attempts
History of Violence Towards Others and Property
History of Falls
Please provide additional details for history listed above
If you have a lawyer, please enter their name and contact information below
Does Journeys Recovery Home have permission to speak to your legal counsel on your behalf?
*
Yes
No
Please give a brief summary of why you would like to come to Journeys Recovery Home
*
Do you understand and acknowledge that Journeys Recovery Home is a Christ-centered program and that being a resident at Journeys Recovery Home requires all residents to actively participate in faith-based related program meetings, volunteer work and church services?
*
Yes
No
Submit
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