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  • Stewards of Recovery

  • 685 1st St, Idaho Falls 83401

  • Format: (000) 000-0000.
  • Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Gender*
  • Are you currently in a romantic Relationship?*
  • Are you employed? *
  • Gang Affiliation?*
  • Do you receive disability?*
  • Do you receive food stamps?*
  • Do you have a valid license?*
  • Do you own a vehicle?*
  • Do you have Medicaid?*
  • Do you have Private Insurance*
  • Do you have a substance abuse problem?*
  • Prior substance abuse treatment?*
  • Are you currently being treated for these conditions?*
  • Do you have diabetes?*
  • Do you take insulin?
  • Are you pregnant?*
  • Are you receiving Prenatal Care?
  • Do you have Children?*
  • Do you have an open case with Child Protection Services?
  • Do you have legal custody of your children?
  • Are you currently on probation or parole?*
  • Have you ever been charged for a violent crime or crime of sexual nature?*
  • Do you have charges pending or are you awaiting sentencing?*
  • {name}
  • Date and Time

  • Release of Information

  • By signing below, I, hereby authorize Stewards of Recovery to release and/or obtain information with respect to any medical, psychiatric, drug and/or alcohol related conditions obtained during the course of diagnosis and/or treatment to/from the individual(s) or healthcare providers listed below. The type of information authorized for disclosure includes, but may not be limited to, that which is indicated below. I understand that my signature below will not have affect on the ability or inability to determine, limit or restrict my treatment.

    I understand that any information released with this consent in regards to treatment, payment and/or healthcare operations may be re-disclosed by the receiving service provider under this initial consent, if and only if, it pertains to my treatment, payment and/or healthcare operations.

    I understand that I have the right to limit or restrict the re-disclosure of my information by other service providers in regards to my treatment, payment and/or healthcare operations

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