It’s time to start your new life…TODAY! Apply for Rivers Edge Recovery Program Name * First Name Last Name Email Phone (###) ### #### Referred By Current Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date Of Birth MM DD YYYY Gender Male Female Social Security Number Marital Status Spouse Name Are you a Veteran Yes No Branch of military Do you have children? If so please list names and ages Name of emergency contact Please list name, relationship and phone number Drivers License Number and State of Issue Do you have a personal vehicle that will be on our property? If so please list: Year | Make | Model Insurance Verification If so list Company and Policy Number Personal History Drug Use History: Alcohol Meth Marijuana Concaine Opiates Heroin Amphetamine Inhalants Have you ever been to a treatment facility for alcoholism and/or drug addiction? Yes No If "yes" list the treatment provider Have you ever attended a support group or received treatment services for substance use or abuse? Yes No Are you employed? Yes No If "yes" name of your employer? Have you ever lived in a Sober Living environment before? Yes No If "yes", provide the name and location of the facility. Are you getting SSI or other non-job related income? Yes No If "yes" list what you are your receiving? What do you expect your monthly income to be next month? If you do not have a job what are your plans for obtaining employment and maintaining the ability to pay your rent? Do you have a probation/parole officer? If so, please list their name and phone # Do you take prescription drugs? If "yes" list drugs and reason (if known) the drug has been prescribed. Do you have any mental health issues? If "yes" what is the diagnosis? Do you have a medical doctor? If "yes" list the doctor's name and phone # When was your last check up? Have you ever tested positive for any of the following? HIV / Hepatitis / TB Do you have any outstanding warrants that you are aware of? If "yes" what county or state? Have you ever been affiliated with a Gang? If "yes" which Gang? Are you still a member of this Gang? Yes No Family History: Alcoholism or Drug Addiction Please list all known relatives with either of these problems Have you ever used drugs intravenously (shot Drugs)? Yes No Have you ever had a blood transfusion? Yes No How long have you been completely clean at this time? Do you need physical detox? Yes No Any physical ailments of handicaps? If yes, please explain Please list all medical problems that you have been diagnosed with including mental health issues: List any Allergies: medications, food or environmental Do you have epilepsy? Yes No Do you wear persription eye glasses or contacts? Yes No Please give a complete history of your alcohol and drug use: Mental Health History Do you express your feeling easily? Yes No Would you rather be around people or alone? Have you lived in close quarters with other people? Yes No Do you have trouble sleeping? If yes, please explain: Do you suffer from nightmares on a regular basis? If yes, please explain: Have you suffered a severe emotional trauma? If yes, please explain: Have you ever tried to commit suicide or thought about it on a frequent basis? if yes, please explain: Have you ever been in counseling before? if yes, please explain Has a psychiatrist diagnosed you with any emotional disorders? if yes, please explain: Have you ever been hospitalized for an emotional problem? if yes, please explain Are you willing to release any mental health records to Rivers Edge Recover Inc.? Yes No Have you ever been molested? Yes No If yes, was it by a family member? Yes No What goals do you hope to achieve while in this program? What is your #1 Priority? Do you understand that this is a faith based program? Y/N if yes explain what you believe that means: Why do you want to a participant in this program? How can we help you to achieve your goals? Have you ever been incarcerated? Y/N If "yes" where? Have you ever been convicted of Violent crimes? Yes No Have you been convicted of child crimes or sexual offences? Yes No Do you have to register as a sex offender ? Yes No DOC Number? Do you have a Driver's License? Yes No Do you have a picture ID? Yes No Do you have a SS card? Yes No Do you have a birth certificate or second form of identification? Yes No Do you owe fines and costs? Yes No I, realize that Rivers Edge Recovery Inc. has been established in compliance with the conditions of statue 2036 of the Federal Anti-Drug Abuse act of 1998, P.L. 100-690, as amended, which provides that federal money loaned to start the house requires the house residents to (A) prohibit all residents from using alcohol or illegal drugs, (B) expel any resident who violates such prohibition, Pays fees, and (D) in accepting these terms, the applicant excludes himself from the normal due process afforded by local landlord-tenant laws. Use this space for additional relevant information: I have read and answered each question honestly all of the material on this application form including the limitations set forth in items above: Please type your name as digital signature: Date MM DD YYYY Thank you!
