Just Breathe Recovery Works Intake Application
Please complete the form thoroughly to start your recovery process.
Please complete the following intake application thoroughly and accurately. Submission of this form does not guarantee acceptance into services or housing. A representative from Just Breathe Recovery Corp will review the application and contact the participant or referral source regarding eligibility and next steps.
SECTION 1 – APPLICATION INFORMATION
Date of Submission
-
Month
-
Day
Year
Date
Date
-
Month
-
Day
Year
Date
Completed By*
*
Please Select*
*
Please Select
Self
Parent/Guardian
Probation Officer
Case Manager
Treatment Provider
DCS Representative
Community Corrections
Other
SECTION 2 – PARTICIPANT INFORMATION
Applicant First Name
*
Applicant Last Name
*
Participant Date of Birth*
*
-
Month
-
Day
Year
Date
Age
Participant Social Security Number*
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Are you/participant a resident of Indiana?*
*
Yes
No
Current County
Please Select
Marion
Hamilton
Hendricks
Johnson
Madison
Hancock
Boone
Shelby
Morgan
Other Indiana County
SECTION 3 – CASE / LEGAL INFORMATION
Do you/participant have an open case?*
*
Yes
No
Do you/participant currently have an open DCS/CHINS case?*
*
Yes
No
Do you/participant have a current felony charge or prior felony conviction?*
*
Yes
No
Case Number
County*
Please Select
Marion
Hamilton
Hendricks
Johnson
Madison
Hancock
Boone
Shelby
Morgan
Other Indiana County
Please upload court documentation that shows a felony charge or conviction
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Are you/participant currently incarcerated?*
*
Yes
No
Are you/participant currently on or required to register on the Indiana Sex and Violent Offender Registry?*
*
Yes
No
Release Date
-
Month
-
Day
Year
Date
Current Facility Contact Details (ie, IDOC location, jail location, or Work Release location)*
*
SECTION 4 – HOUSING & RECOVERY INFORMATION
Current Housing Status
Homeless
Transitional Housing
Staying with Family/Friends
Recovery Housing
Shelter
Own Apartment/Home
Incarcerated
Other
Are you currently homeless or at risk of homelessness?
Yes
No
Are you currently in recovery or seeking recovery support?
Yes
No
Do you have a Recovery Works referral or approval?
Yes
No
Unsure
Referral Source / Agency Name
Referring Person’s Name
Referring Person’s Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Submit
Should be Empty: