Recovery Participant Application
For people in recovery, veterans, domestic violence survivors, and returning citizens; send an email for the Transitional Application
DEMOGRAPHICS
Legal Name:
*
First Name
Last Name
Legal Middle Name:
Preferred Name (Nickname):
If you have been known by an alternative name, enter it below.
Date of Birth:
*
-
Month
-
Day
Year
Date
Mobile/Cell #:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Social Security #:
*
Email:
*
example@example.com
I, applicant, consent to be contacted by Starts With Love Foundation via SMS, email or phone using the information provided above for the purposes of reviewing my application.
*
Yes
No
Do you consent to a background check? Note: Starts With Love Foundation does not accept anyone with a sexual crime, violent crime or crime of arson.
*
Yes
No
What is your marital status:
*
Single
Married
Engaged
Separated
Divorced
Domestic Partner
Widow
If you have children, list their names and ages.
What is your gender:
*
Male
Female
Other
What is your race/ethnicity:
*
American Indian or Alaska Native Indian
Asian
Black or African American
White
Hispanic
Hawaiian
Other Pacific Islander
Other
Are you a veteran:
*
Yes
No
Are you SSI or SSDI? SSI=Social Security Income; SSDI=Social Security Disability Income
*
Yes
No
Are you currently enrolled in school:
*
Yes, full-time
Yes, part-time
No
Other
What is the highest level of education completed:
*
Elementary
High School / GED
Some college
College Degree
Master's Degree
Trade School
Who is completing the application:
*
Self
Family Member
Friend
Case Manager
Discharge Coordinator
Other
Are you fleeing a domestic violence situation:
*
Yes
No
Are you in the process of family reunification:
*
Yes
No
Do you have children?
*
Yes
No
CURRENT LIVING SITUATION
We understand that everyone has a unique journey. In order to better understand your transition to our program, it is helpful to understand your current living situation.
What best describes your current living situation:
*
I am living by myself
I am living with family
I am living with a friend
I am living with my roommate(s)
I am at a sober living home
I have no permanent place to live and I am currently experiencing homelessness
Other
Where are you currently living:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How long have you lived at the residential address above:
*
Less than 1 year
1 to 5 years
Over 5 years
Other
Do you plan to return to this living situation:
*
Yes
No
Maybe
Other
Back
Next
Save
Age:
PROGRAM COST & DETAILS
How will the program fees be paid:
*
Self
Family
Friend
Church
Tribe
Other
Do you have any concerns sharing a room (all rooms are shared):
*
Yes
No
Are you able to go up and down stairs (our home is a two-story home):
*
Yes
No
Other
Are you able to perform household chores:
*
Yes
No
Other
Back
Next
Save
PERSONAL CONTACTS
Include at least one Emergency Contact and one Release of Information Contact. Others to include: your sponsor, probation officer, parole officer, and case manager.
Emergency Contact Name [This is who will be contacted in the case of an emergency]:
*
First Name
Last Name
Emergency Contact Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Email Address:
example@example.com
Emergency Contact Relationship:
*
Spouse
Significant Other
Parent
Sibling
Adult Child
Friend
Sponsor
Release of Information is ok
Case Manager
Parole Officer
Probation Officer
Other
Release of Information Contact Name:
*
First Name
Last Name
Release of Information Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Release of Information Email Address:
example@example.com
Release of Information Relationship:
*
Spouse
Parent
Sibling
Adult Child
Significant Other
Friend
Sponsor
Case Manager
Parole Officer
Probation Officer
Emergency Contact also
Other
Parole / Probation Officer Name (if applicable):
First Name
Last Name
Parole / Probation Officer Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Add Another Personal Contact:
*
Yes
No
Back
Next
Save
Contact #4 Name:
First Name
Last Name
Contact Name #4 Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Contact #4 Email:
example@example.com
Contact #4 Relationship:
Spouse
Parent
Significant Other
Friend
Sponsor
Case Manager
Probation Officer
Parole Officer
Emergency Contact
Release of Information is ok
Add another contact:
Yes
No
Back
Next
Save
Contact #5 Name:
First Name
Last Name
Contact #5 Phone #:
Please enter a valid phone number.
Format: (000) 000-0000.
Contact #5 Email #:
example@example.com
Contact #5 Relationship:
Spouse
Parent
Significant Other
Friend
Sponsor
Case Manager
Probation Officer
Parole Officer
Emergency Contact
Release of information is ok
Add another contact:
Yes
No
Back
Next
Save
Contact #6 Name:
First Name
Last Name
Contact #6 Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Contact #6 Email:
example@example.com
Contact #6 Relationship:
Spouse
Parent
Significant Other
Friend
Sponsor
Case Manager
Probation Officer
Parole Officer
Emergency Contact
Release of Information is ok
Back
Next
Save
SUBSTANCE USE / HEALTH CARE
Substance of Choice - choose all that apply:
*
Alcohol
Amphetamines
Barbituates
Benzodiazepine
Cocaine
Depressants
Ecstasy
Fentanyl
Heroin
Marijuana/THC
Nitazenes (benzimidazole-based opioids)
Oxycodone
PCP
Prescription Opioids
Stimulants
Other
What was the last substance(s) used and when:
*
For how many years have you been using alcohol and/or drugs:
*
Do you smoke or vape:
*
Yes
No
List any food allergies: (Type "none" if you have no known allergies.)
*
List any allergies to medications or seasonal allergies: (Type "none" if you have no known allergies.)
Do you have any health problems:
*
Heart
High Blood Pressure
Epilepsy
Arthritis or Rheumatism
Cancer
Emphysema or Chronic Bronchitis
Diabetes
Stroke
Broken or Fractured Bone
Chronic Nervous or Emotional Problems
Parkinson's disease
Teeth or Gums
None
Other
Do you have any of the following clinical diagnosis:
*
Mental Disorder
Bipolar Disorder
Anxiety Disorder
Schizophrenia
Post-Traumatic Stress Disorder
Obsessive Compulsive Disorder
Major Depressive Disorder
Psychosis
Eating Disorder
Mood Disorder
Psychological Stress
Personality Disorder
Behavioral Disorder
Dissociative Identity Disorder
Generalized Anxiety Disorder
Mixed Anxiety Depressive Disorder
Borderline Personality Disorder
Self-harm
Social Anxiety Disorder
Schizoaffective Disorder
Antisocial Personality Disorder
Major Depressive Episodes
Paranoia
Intellectual Disability
Learning Disability
Somatic Symptom Disorder
Seasonal Affective Disorder
Spectrum Disorder
Postpartum Depression
Psychomotor Agitation
Gender Dysphoria
Developmental Disability
Other
Do you identify patterns in other areas of your life that may have some addictive qualities:
*
None
Internet
Food
Relationships
Money
Shopping
Sex
Gambling
Other
Are you experiencing any shortness of breath, coughing, fever, or other symptoms of Covid and/or a flu:
*
Yes
No
Other
Have you traveled outside of the country in the last 30 days:
*
Yes
No
MEDICATIONS - Are you currently taking any over-the-counter medications:
*
Yes
No
MEDICATIONS - Are you currently taking any prescription medications:
*
Yes
No
Back
Next
Save
Name of Medication
When do you take the medication - how often and time of day?
Example: 2 x daily/AM & PM
Add another medication?
Yes
No
Medication #1: Include name, dosage, how often & time of day is the medication taken:
Medication #2: Include name, dosage, how often & time of day is the medication taken:
Medication #3: Include name, dosage, how often & time of day is the medication taken:
Medication #4: Include name, dosage, how often & time of day is the medication taken:
Medication #5: Include name, dosage, how often & time of day is the medication taken:
Medication #6: Include name, dosage, how often & time of day is the medication taken:
Medication #7: Include name, dosage, how often & time of day is the medication taken:
Medication #8: Include name, dosage, how often & time of day is the medication taken:
Medication #9: Include name, dosage, how often & time of day is the medication taken:
Medication #10: Include name, dosage, how often & time of day is the medication taken:
Medication #11: Include name, dosage, how often & time of day is the medication taken:
Medication #12: Include name, dosage, how often & time of day is the medication taken:
If you have additional medications, add them to this response
Back
Next
Save
RECOVERY
What is your clean or sober date:
*
-
Month
-
Day
Year
Are you currently in a treatment program?
*
Yes
No
Treatment Programs: List out treatment programs you have been to and details:
Which type of meetings do you attend:
*
None
Alcoholics Anonymous (AA)
Narcotics Anonymous (NA)
SMART Recovery
Celebrate Recovery
Medication Assisted Treatment (MAT)
Other
Do you have a sponsor:
*
Yes
No
Do you have a recovery coach:
Yes
No
Do you have a probation or parole officer?
*
Yes
No
Other
Back
Next
Save
ASSISTANCE
Do you have immediate needs such as clothing or toiletries:
*
Yes
No
Do you need assistance with any self-help, support group and/or networks within the local community:
*
Yes
No
Do you need help to renew any forms of identification:
*
Yes
No
Do you need assistance with any food programs:
*
Yes
No
Back
Next
Save
COURTS & CRIMINAL JUSTICE
DOC Number (if applicable):
Select all legal requirements that apply:
*
Probation
Parole
Drug Court
House Arrest
None
Other
Do you have any past or present charges against you:
*
Yes
No
Do you have any court ordered treatment requirements:
*
Yes
No
Do you have any pending sentencing or possible jail time upcoming:
*
Yes
No
Other
Are you required to register with any authority for any reason:
*
Yes
No
Are there any "no contact" or restraining orders against you or by you:
*
Yes
No
Have you been charged or convicted of a felony:
*
Yes
No
Have you been charged or convicted of arson:
*
Yes
No
Are you required to register as a sex offender:
*
Yes
No
Do you have a requirement for Community Service:
*
Yes
No
Back
Next
Save
Charge #1: Include charge, date of the charge, city/county, and status
Charge #2: Include charge, date of the charge, city/county, and status
Charge #3: Include charge, date of the charge, city/county, and status
Charge #4: Include charge, date of the charge, city/county, and status
Charge #5: Include charge, date of the charge, city/county, and status
Back
Next
Save
EMPLOYMENT
Are you employed:
*
Full-time
Part-time
Seeking employment
No
Other
Name of employer:
Employment location - cross streets:
Skills:
Back
Next
Save
ADMISSIONS
When would you like to move in?
*
-
Month
-
Day
Year
Date
Do you expect to move in on time?
*
Yes
No
Other
Do you have a personal relationship with anyone that lives in or volunteers at a Starts With Love Foundation home?
*
Yes
No
Other
Have you previously stayed at a Starts With Love Foundation home?
*
Yes
No
Other
How did you hear about Starts With Love Foundation's homes?
*
Detox/Treatment Center
Another Recovery/Sober Living Home
Friend or Family member
AzRHA Housing Provider Directory
Craigslist
FB Marketplace
Roomies.com
Google
Other
Back
Next
Save
Transportation
What is your primary mode of transportation?
*
Public Transit
Bike
Scooter
Family or Friend
Personal Vehicle
Family or Friend's Vehicle
Rental Car
Other
Do you have a valid driver's license or state issued identification card?
*
Yes, driver's license
Yes, state issued identification card
No
Other
What is your driver's license number or State ID # (and list state if not AZ)?
Is there anything else you would like to share that you feel would be helpful:
Signature
Save
Submit
Submit
Should be Empty: