THE CROSSINGS RESIDENTIAL RECOVERY PROGRAM
This is an official application for admission to the The Crossings, a residential addiction and substance abuse recovery program. Information submitted on this application is confidential and stored on a secure server.
The application should take approximately 30 minutes to complete.
Your signature below indicates that you have voluntarily and free of coercion, read and agree to submit to the guidelines of The Crossings. Upon the review of your completed application and the available bed space, you will be notified of the next steps.
Please be as accurate as possible when answering the questions on this application. All questions must be completed for this application to be processed. Adding to or minimizing your history does not influence your application outcome. Incomplete or falsified information submitted on this application is subject to denial.
Applicant's Name:
Applicant's Signature:
Date:
-
Month
-
Day
Year
Date
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Applicant Assistance
If you are completing this application with the prospective client or on their behalf, please submit your information below.
Assistant First Name
Assistant Last Name
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Relationship to Applicant
Re-entry Navigator
Attorney
Case Worker
Probation Officer
Chaplain
Counselor
Family Member
Friend
OTHER
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Applicant Information
Name:
First Name
Middle Initial
Last Name
Maiden Name:
DOB:
-
Month
-
Day
Year
Date
SSN:
DC Number:
Email Address:
example@example.com
Primary Phone:
Format: (000) 000-0000.
Gender:
Male
Female
Veteran?
Yes, I am a US Veteran.
Ethnicity/Race
Asian
Black/African American
Hispanic/Latinx
Native American or Alaska Native
Native Hawaiian or Other Pacific Islander
White
Other
Current Housing Status
I am currently experiencing homelessness
I am living in my own home.
I am currently incarcerated.
I am in a temp. housing situation/program.
Other
Street Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
If applicable what is the name of the program, jail, or prison where you are currently located?
Education Level
Some High School
High School
Vocational/Technical Degree
Associates Degree
Bachelor's Degree
Master's Degree or above
Do you have a copy of your Drivers License?
Yes
No
Do you have a copy of your Social Security Card?
Yes
No
Do you have a copy of your Birth Certificate?
Yes
No
Do you have a copy of your DD214 (Veterans only)?
Yes
No
What languages do you speak fluently?
English
Spanish
French
Chinese
Arabic
Other
What other cities have you lived in?
Have you ever been a client of The Crossings before
Yes
No
If so, what program(s) and when?
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Income
Please indicate any sources of income you receive each month and the amount per month.
Employment:
Unemployment:
Social Security Income (SSI):
WIC:
HUD:
Cash Assistance:
Other:
Other:
TOTAL MONTHLY INCOME:
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Criminal Justice System
Do you have any pending or prior charges?
Pending
Prior
NONE
Criminal Justice System
Rows
Date of Charge
City
Charge Type
Disposition
1
2
3
4
5
6
Have you been sentenced?
Yes
No
What is your EOS date?
Probation or Parole Status?
I am NOT on probation or parole
I am on probation
I am on parole
What are the terms of your probation or parole?
Do you currently have an attorney or public defender?
No
Attorney-Appointed
Attorney-Retained
Public Defender
Attorney/Public Defender Name:
Attorney/Public Defender Phone:
Attorney/Public Defender Email:
Was a victim physically harmed in any of your charges or convictions?
Yes
No
If so, please describe the situation.
Have you ever been required to register as a sex offender?
Yes
No
If so, when were you required to file and what were the charges?
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Substance Abuse History
When was the last time you used drugs or alcohol?
Do you feel that alcohol or drugs are a problem for you?
Yes
No
Have you ever been arrested while under the influence or high?
Yes
No
Have you ever needed more alcohol or drugs to get the same effect?
Yes
No
Has anyone ever complained about your behavior?
Yes
No
Have you ever tried to cut down or stop using alcohol or drugs?
Yes
No
How old were you when you first noticed that you had a problem with drugs and or/alcohol?
[Substance Abuse History continued on the next page]
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Substance Abuse Survey
Rows
Have you used this substance?
How long did you use this substance for?
How often did you use it during that time?
Alcohol
Never
Used in the past
Used in the last 7 days
Never
Less than 1 mo.
1-6 months
6-12 months
1-2 years
2-5 years
5+ years
10+ years
Never
Daily
Weekly
Monthly
Marijuana
Never
Used in the past
Used in the last 7 days
Never
Less than 1 mo.
1-6 months
6-12 months
1-2 years
2-5 years
5+ years
10+ years
Never
Daily
Weekly
Monthly
Hallucinogenic
Never
Used in the past
Used in the last 7 days
Never
Less than 1 mo.
1-6 months
6-12 months
1-2 years
2-5 years
5+ years
10+ years
Never
Daily
Weekly
Monthly
Barbiturates
Never
Used in the past
Used in the last 7 days
Never
Less than 1 mo.
1-6 months
6-12 months
1-2 years
2-5 years
5+ years
10+ years
Never
Daily
Weekly
Monthly
Amphetamine
Never
Used in the past
Used in the last 7 days
Never
Less than 1 mo.
1-6 months
6-12 months
1-2 years
2-5 years
5+ years
10+ years
Never
Daily
Weekly
Monthly
Methamphetamine
Never
Used in the past
Used in the last 7 days
Never
Less than 1 mo.
1-6 months
6-12 months
1-2 years
2-5 years
5+ years
10+ years
Never
Daily
Weekly
Monthly
Heroin
Never
Used in the past
Used in the last 7 days
Never
Less than 1 mo.
1-6 months
6-12 months
1-2 years
2-5 years
5+ years
10+ years
Never
Daily
Weekly
Monthly
Methadone
Never
Used in the past
Used in the last 7 days
Never
Less than 1 mo.
1-6 months
6-12 months
1-2 years
2-5 years
5+ years
10+ years
Never
Daily
Weekly
Monthly
Cocaine
Never
Used in the past
Used in the last 7 days
Never
Less than 1 mo.
1-6 months
6-12 months
1-2 years
2-5 years
5+ years
10+ years
Never
Daily
Weekly
Monthly
Opiates
Never
Used in the past
Used in the last 7 days
Never
Less than 1 mo.
1-6 months
6-12 months
1-2 years
2-5 years
5+ years
10+ years
Never
Daily
Weekly
Monthly
K2/Spice
Never
Used in the past
Used in the last 7 days
Never
Less than 1 mo.
1-6 months
6-12 months
1-2 years
2-5 years
5+ years
10+ years
Never
Daily
Weekly
Monthly
Kratom
Never
Used in the past
Used in the last 7 days
Never
Less than 1 mo.
1-6 months
6-12 months
1-2 years
2-5 years
5+ years
10+ years
Never
Daily
Weekly
Monthly
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Mental Health History
Do you have a mental health diagnosis?
Yes
No
If so, what is your diagnosis?
Are you experiencing auditory or visual hallucinations?
Yes
No
If prescribed psychotropic medication by a medical professional, are you willing to comply?
Yes
No
Have you been prescribed medication for your diagnosis?
Yes
No
Please list the medications.
Do you need assistance getting your medication?
Yes
No
Have you ever attempted suicide?
Yes
No
If so, when?
What were the circumstances around this event?
Were you hospitalized?
Yes
No
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Health and Medical Information
Do you have a medical diagnosis?
Yes
No
If so, what is your diagnosis?
Have you been tested for COVID-19?
Yes - I tested positive
Yes - I tested negative
No
When did you take your most recent COVID-19 test?
Are you able to carry out daily living activities* without assistance?
Yes
No
*i.e. caring for your personal needs such as preparing meals, cleaning living space, personal hygiene
If not, please explain why not.
Is it possible that you are pregnant?
Yes
No
Are you able to carry out full time work?
Yes
No
Are you currently experiencing a cough, fever, or shortness of breath?
Yes
No
Have you been exposed to anyone who has tested positive for COVID-19 in the last 14 days?
Yes
No
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Employment History
Rows
Employer
Position
Start Date
End Date
1
2
3
What kind of work are you trained to do?
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Housing History
How many times have you experienced homeless in the past three years?
Where did you sleep last night?
Jail/Prison
Outside
Friends home/Couch
My own home/apt
Shelter
Institution
Other
When was the last time you had a safe, permanent place to live?
How long did you live there?
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Freedom Program
List three goals that you hope to achieve by participating in this program.
Is there anything else that you would like us to know?
How did you hear about us?
Friend/Family
A Previous Client
Search Engine (ex: Google)
Social Media
Attorney/Public Defender
Another human services agency
Counselor
Other
Your signature below indicates that you have voluntarily and free of coercion read and agree to submit to the guidelines of The Crossings as referenced in this document. Upon the review of your completed application and the available bed space, you will be notified of the next steps.
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Last Name
Today's Date
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