ADDICTION RECOVERY APPLICATION
Fill out the form carefully for registration
Client Name
*
First Name
Middle Name
Last Name
Client Age:
*
Client Birth Date:
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Client Address:
*
Street Address
City
County
State / Province
Postal / Zip Code
Client Mobile Number
*
Client E-mail
*
example@example.com
Referred By
First Name
Last Name
Do you know or are you acquainted with anyone connected to Valley Rescue Mission?
*
YES
NO
Name of person:
Why are you applying to a recovery program at this time?
*
What are your immediate needs?
*
What are your present goals?
*
What are your strengths?
*
What are your weaknesses?
*
Back
Next
Family Information
Son/Daughter
First Name
Last Name
Age/DOB
Son/Daughter
First Name
Last Name
Age/DOB
Son/Daughter
First Name
Last Name
Age/DOB
Emergency Contact
Emergency Contact Name:
*
First Name
Last Name
Emergency Contact Relationship:
*
Emergency Contact Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Number
*
Do you have family in Muscogee County or the immediate area?
*
YES
NO
Name
First Name
Last Name
Relationship/Supportive?
Name
First Name
Last Name
Relationship/Supportive?
Please list family outside of Muscogee County or immediate area:
Is there any further information you can offer which might help us in determining your admission?
Alcohol/Drug History
Amount/How Often Used
Date Started
Date of Last Use
Cocaine/Crack
Marijuana
Heroin
Alcohol
Nicotine
Prescription Drugs
Methamphetamines
Other
Age at first use:
Longest period of sobriety:
Drug of Choice:
Back
Next
Previous Treatment Programs
* Previous residential treatment centers:
Name of Previous Program
Admission Date:
Discharge Date:
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Previous Program
Admission Date:
Discharge Date:
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Previous Outpatient Treatment Programs
* Previous residential treatment centers:
Name of Previous Outpatient Treatment Program:
Admission Date:
Discharge Date:
Phone Number:
Please enter a valid phone number.
Address of previous outpatient treatment program:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Ongoing Habits
Do you smoke?
*
YES
NO
Are you willing to quit?
YES
NO
Suicidal Tendencies
Have you ever attempted suicide?
*
YES
NO
How many times?
List the date, circumstances, treatment and diagnosis:
Do you have current suicidal thoughts?
*
YES
NO
If yes, please describe:
Back
Next
Mental Health Treatment
Hospitalized for emotional or nervous reasons?
*
YES
NO
Have you ever been in therapy?
*
YES
NO
If yes, list Therapist, type of therapy, and dates:
Were medications prescribed?
YES
NO
If yes, describe type of medication, dates prescribed and duration:
Please describe any personal or family psychiatric history:
Have you ever experienced any of the following types of abuse?
*
Childhood
Adult
None
Physical Abuse:
Emotional or Verbal Abuse:
Sexual Abuse:
Are you presently in contact with anyone who is/was abusive to you?
*
YES
NO
If yes, please describe:
Have you ever been arrested?
*
YES
NO
Are you a registered sex offender?
*
YES
NO
Any pending charges?
*
YES
NO
If yes, please list dates, violation, sentence requirements and pending court dates:
Are you on probation/parole?
*
YES
NO
Name, address, and telephone number of probation/parole officer:
Back
Next
Medical History
Are you currently under medical supervision?
*
YES
NO
If yes, list name of physician, phone number, address, and date of last physical
Have you ever had any of the following
*
None
Seizers
Heart Disease
Respiratory Problem
Diabetes
Hepatitis
Venereal Disease
Vision Problems
Tuberculosis
Hearing Problems
Other
If you checked any of the above, please explain:
Are you currently taking medications
*
YES
NO
If yes, please list the medications and the reasons for taking here:
If there are medications that you SHOULD be taking, list them here:
Have you had any major/minor surgery in the last five years?
*
YES
NO
If you've had major/minor surgery, please explain here:
What is your education background?
*
High School
GED
Some College
Tech
College Degree
Other
Are you a veteran?
*
YES
NO
If yes, list branch of service and discharge type:
Employment History
Last employer/date/location:
Still employed?
YES
NO
Housing / Credit History
Last residence:
*
Reason vacated:
Ever received housing assistance:
*
YES
NO
If yes, from whom:
Do you owe the housing authority money?
*
YES
NO
If yes, how much:
Are you presently homeless?
*
YES
NO
If yes, for how long:
Do you have any outstanding debts? (loans, credit cards, bills, etc.)
Income
Are you currently receiving medicare, medicaid, disability or other government aid?
*
YES
NO
If yes, what is the type and amount:
Are you on food stamps/EBT?
*
YES
NO
If yes, what is the name and office of case worker:
Other income source(s) and amount per week/month/year:
If yes, what is the name and office of case worker:
If selected for residence in this program, is there anything that we should know about you that would hinder your ability to sweep, mop, lift, mow, or do normal household chores?
*
YES
NO
If yes, please explain:
Any additional comments you wish to make:
Note:
This center is not a medical or psychiatric facility: therefore prospective students must be medically as well as psychiatrically cleared prior to admission. The requested medical information within this application for consideration of admission is vitally important and is required before a decision can be rendered as to the appropriateness of our facility for prospective students. If mental health evaluation/documentation is requested, that also must be received before a final decision can be made regarding placement in the recovery program. If within 30 days of admissions, it is noted that the client is inappropriate due to medical or psychiatric reasons about which we were uninformed prior, this facility reserves the right to refer the student to another facility or back to the referring agency.
Signature Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Signed Signature
*
Use PC mouse , rubber tipped stylus, or finger depending on device being used.
Submit
Clear Fields
Should be Empty: