Intake Application

Intake Application

Journeys Recovery Home
Name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Preferred Method of Contact

Phone CallTextEmail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Health Card #
Health Card Expiry Date
Do you have any chronic illnesses, physical disabilities or medical conditions? (e.g., diabetes, hypertension)*

YesNo
If yes, please specify
Are you able to go up and down the stairs?*

YesNoNot without Difficulty
Have you had any surgeries or hospitalizations in the past?*

YesNo
If yes, please provide details
Are you currently taking any medications?*

YesNo
If yes, please list the name of medication, dosage and reason for use
Do you have any allergies? (e.g., food, medication, environmental)*

YesNo
If yes, please specify
Do you smoke?*

YesNo
If yes, how many cigarettes per day
Do you consume alcohol?*

YesNo
If yes, how often and how much
Do you use recreational drugs?*

YesNo
If yes, please specify what drug(s)
How often do you use drugs or alcohol?*

DailySeveral times a weekOnce a weekRarelyNeverOther
Are you on Methadone or Suboxone?*

NoMethadoneSuboxone
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 PsychosisEating DisorderChronic PainSelf-harmAnxietyDepressionSuicidal ThoughtsThoughts of Harming OthersAbuseHomelessnessLonelinessAngry OutburstsNone of the above
Have you ever been diagnosed with any of the following? (Check all that apply)*

Anxiety DisorderDepressionBipolar DisorderBorderline Personality DisorderPTSDDementiaCognitive DisorderNarcissistic Personality DisorderObsessive Compulsive DisorderDissociationEating DisorderAutismNone of the aboveOther
If yes, when did you receive this diagnosis?
How would you describe your current mental health status?*

1

2

3

4

5

1 is Poor, 5 is Excellent
Do you have any current or on-going legal issues? (Please select all that apply)*

NoProbationOn BailCurrent ChargesUpcoming Court DatesSexual ChargesActive WarrantCurrently IncarceratedHouse ArrestPeace BondNo-Contact OrderRestraining 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 SettingHistory of Self-harmHistory of Suicide AttemptsHistory of Violence Towards Others and PropertyHistory 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?*

YesNo
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?*

YesNo
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