This can be the first day of the rest of your life Let’s work together Todays Date * MM DD YYYY Requested move in date * MM DD YYYY Name * First Name Last Name Phone * Country (###) ### #### Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Social Security Number * Date of birth * MM DD YYYY Emergency Contact * Name First Name Last Name Emergency Contact Phone * (###) ### #### Emergency Contact Relationship to you * Father Mother Brother Sister Son Daughter Significant other Drugs of Choice * Alcohol Heroin Crack/Cocaine Crystal Meth Ketamine Barbiturates Sedatives Benzodiazepines Fentanyl PCP MDMA (Ecstasy) Cannabis (Marijuana, THC) Synthetic cannabinoids (Spice, K2) Synthetic cathinones (Bath salts) Date of last use * Days Sober * Physical and Mental health * Please check all Diabetes Type 1 Diabetes Type 2 Do you take Insulin Asthmatic High Blood Pressure Schizophrenia Bi-polar Anxiety Depression Schizoaffective Hepatitis A, B, or C Pancreatitis Panic Disorder ADD Other None Epilepsy Seizure Medications Fluoxetine (Prozac) Sertraline (Zoloft) Escitalopram (Lexapro) Paroxetine (Paxil) Citalopram (Celexa) Venlafaxine (Effexor) Duloxetine (Cymbalta) Bupropion (Wellbutrin) Mirtazapine (Remeron) Lithium (Lithobid) Lamotrigine (Lamictal) Valproate (Depakote) Haloperidol (Haldol) Chlorpromazine (Thorazine) Aripiprazole (Abilify) Olanzapine (Zyprexa) Quetiapine (Seroquel) Risperidone (Risperdal) Clozapine (Clozaril) Benzodiazepines (short-term use) Buspirone (Buspar) Hydroxyzine (Vistaril) Gabapentin (Neurontin) Pregabalin (Lyrica) Valproate (Depakote) Lamotrigine (Lamictal) Levetiracetam (Keppra) Topiramate (Topamax) Zonisamide (Zonegran) MAT Medication Suboxone (buprenorphine + naloxone) Subutex Sublocade (injectable form) Naltrexone Vivitrol (injectable form) Methadone List all medications if none write "NA" * Health Conditions if none write "NA" * Have you ever been convicted of * Arson Sex offense None Probation officer Name and Number and criminal record About you Please tell us a little about your self. Referral Contact * First Name Last Name Email Phone * Any information that would be helpful. Confirm client has had a negative urine screen within 72 hours of arrival at Recovery First * Yes negative urine screen No positive urine screen IMPORTANT NOTICE: * Recovery First Sober Living is a recovery home which requires expulsion, without prior notice or refund of deposit and fees, of any resident member who is found to be: 1) using alcohol or drugs; 2) engaging in disruptive behavior; or 3) in default of payment of monthly membership fee. All resident tenants of Recovery First Sober Living are members of our recovery home. Medications that are controlled substances must be stored in a locked container. I have read the above notice and understand that I am applying for membership of Recovery First Sober Living as a member of a recovery home. I agree to abide by the responsibilities and requirements of the house and fully subject myself to the rules of the home, which include periodic/random drug testing which the sober house pays for. I understand that I am subject to immediate expulsion from the home if any of the following occur: 1) I use alcohol or drugs (other than prescribed medications); 2) I engage in disruptive behavior (continued patterns of irresponsible behavior are considered disruptive behavior). Recovery Housing * Pathways to recovery "90 day scholarship" 3/4 sober living " 30 - 60 days sober" Funding Source Stella Probation CTC Self-Pay Pathway's to Recovery I have read Our Program for Pathways to recovery and would like to participate * Yes No Are you currently in treatment I can’t we can stay sober. We will be in touch within 48 hours
