Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
*
Emergency Contact Phone Number
*
Referred by
*
Education Level
*
Do you use tobacco: If yes how much per day
*
Do you receive any other funding?
*
Drug of choice?
*
Non prescribed drug use within the last year?
*
How many times have you been in treatment?
*
List where and when
*
How many times have you completed treatment?
*
Have you ever AMA?
*
Are you currently in out-patient treatment?
*
Where?
*
Have you done IOP before?
*
If so where?
*
Did you complete?
*
Are you interested in IOP?
*
Clean date from alcohol or drug use since?
*
Prescribed Suboxone
*
Yes
NO
Prescribed Methadone
*
Yes
NO
Prescribed Vivtrol
*
Yes
NO
Have you lived in a recovery house?
*
Would you be interested in living in a recovery house?
*
What area would you like to be in?
*
Have you been to a 12 step meeting?
*
Do you have any current medical issues or needs?
*
Do you have mental health issues?
*
Have you had a psych evaluation?
*
Are you taking any medications?
*
If so what are you taking?
*
Are you employed?
*
If not are you willing to fill out 7 applications a week until you find employment?
*
How much do you make every 2 weeks?
*
Do you have any charges pending?
*
Are you on probation or parole?
*
Explain why you want this opportunity to change your life?
*
Submit
Should be Empty: