INTAKE FORM

GENERAL INFORMATION

Full Name*:

Pronouns:

Last four (4) Digits of Social Security Number*:

Birth Date*:

Age*:

Race:

Gender:

Sexual Orientation:

Are you currently experiencing any challenges with your identified orientation:YesNo

If yes, please explain:

Phone Number*:

Email Address*:

Current Residence:Own HomeParentsRelativeFriendDetoxIncarceratedHomelessOther

If other, please explain:

Address:

Visible tattoos?:YesNo

If yes, please describe:

Is your license valid:YesNo

If no, explain how to reinstate:

Do you have a vehicle:YesNo

If yes, what is the make/model:

What is your vehicle tag number:

Do you have a state ID:YesNo

Marital Status:SingleMarriedSeparatedDivorcedWidowed

Name of Spouse:

Spouse's Phone:

Number of Children:

Names/Ages of Children:

Guardian Name:

Guardian Phone:

Is DFCS Involved:YesNo

If yes, provide case worker name:

Case worker phone number:

Case worker fax number:

Do you owe child/spouse support:YesNo

If yes, how much:

Highest level of completed education:GEDHigh schoolSome collegeCollege degreeOtherDid not graduate

If other, please explain:

If you did not graduate, please explain:

Military experience:YesNo

If yes, which branch and when:

EMERGENCY CONTACT INFORMATION

Emergency Contact Name:

Emergency Contact Relationship:

Emergency Contact Phone Number:

Additional Emergency Contact Name:

Additional Emergency Contact Relationship:

Additional Emergency Contact Phone Number:

What support person(s) will agree to the Family Restoration Group?

EMPLOYMENT STATUS

Employment Status:UnemployedEmployedSelf-employedContract labor/services

Current Employer:

How long have you been employed:

Previous Employer:

How long were you previously employed:

Additional Previous Employer:

How long were you previously employed:

What was your longest full-time job and how long did it last:

LEGAL STATUS

Referred By:

Mandating Party:ProbationParoleAccountabilityOther

Mandating Party Name & County(if multiple, list all):

Mandating Party Phone:

Mandating Party Fax:

Mandating Party Email:

Have you ever been incarcerated:YesNo

Date of last incarceration:

Incarceration Charges:

Any Pending Cases:YesNo

If pending cases, what county(ies):

Who is your attorney/public defender:

Attorney/public defender phone:

Attorney/public defender fax:

Attorney/public defender email:

Have you ever been in prison:YesNo

If yes, how many times and what were the charges?

Have you ever been arrested for sex crimes:YesNo

Have you ever been arrested for arson:YesNo

Have you ever been involved in a gang(s):YesNo

If yes, please explain your gang involvement:

HEALTH STATUS

Rate your health:ExcellentGoodAverageDeclining

Height:

Weight:

Any recent health changes:YesNo

Any physical or medical conditions(list all):

Do you smoke or use tobacco:YesNo

Do you vape:YesNo

Known allergies(list all):

Mental health conditions(list all):

Current medications(list all):

Prescribing Doctor or Agency:

Previous inpatient/hospitalizations due to psychiatric conditions?YesNo

If yes, how many times and for what? Please explain:

Family history of mental health conditions:YesNo

If yes, please explain:

Do you have any non substance addictive behaviors?YesNo

If yes, please select all that apply:GamblingSex/PornInternet/Social MediaFood (ie: binging/purging)Video GamesShoppingOther

If other, please explain:

Have you experienced trauma:YesNo

If yes, please select all that apply:SexualVerbalPTSDMentalPhysicalOther

If other, please explain:

Attempted suicide:YesNo

Current Suicidal thoughts:YesNo

If yes, please explain:

Acts of self-harm:YesNo

If yes, what type of self-harm?

What is the date of your last self-harm?

Current thoughts of self-harm?YesNo

If yes, please explain

Any communicable diseases or viruses, such as HIV/AIDS, Hep C, STI’s?YesNo
(Please note that this will not have an effect on your acceptance.)

If yes, please list all:

Are you receiving treatment for the above?

Receive Government Assistance:DisabilitySSI

Do you receive(check all that apply): Food StampsMedicaidMedicareN/A

Assistance amount:

Do you have medical insurance:YesNo

If yes, who is your medical provider:

Can you work:YesNo

Please explain:

SUBSTANCE USE HISTORY

NOTE: Must not be in need of detox for admission.

Check all that apply:
I have found myself taking the substance in larger amounts or for longer than I meant toI have wanted to cut down or stop using the substance but could not manage to do soI have spent a lot of time getting/ using/or recovering from use of the substanceI have experienced cravings and urges to use the substanceI have not been abel to do what I should at work/home/or school because of the substance useI have continued to use it even when it causes problems in relationshipsI have given up important social/occupational/and recreational activities because of substance useI have used substances again and again - even when it puts me in dangerI have continued to use - even when I know I have a physical or psychological problem that could have been caused or made worse by the substanceI have found myself needing more of the substance to get the effect I want (tolerance)I have developed withdrawal symptoms - which can be relieved by taking more of the substance

How old were you when you first used alcohol:

How old were you when you first used drugs:

What substances did you use:

Date of last substance use:

Last substance used & quantity:

Addicted to drugs or alcohol:YesNo

Which are you addicted to:DrugsAlcoholBoth

What is/are your substance(s) of choice:

IV drug use:YesNo

If yes, what substance(s):

Family history of substance use:YesNo

If yes, please explain:

Previous treatment:YesNo

Where were you previously treated:

How long were you treated:

Did you complete treatment:YesNo

If no, why?

Additional Previous treatment:YesNo

Additional Where were you previously treated:

Additional How long were you treated:

Additional Did you complete treatment:YesNo

If no, why?

What kind of problems has drug/alcohol use caused you:

How many years/months of substance use:

Attended AA or NA:YesNo

What is the longest amount of time you've gone without use:

How did you stay abstinent:

(NOTE: Must not be in need of detox for admission. If you have a positive screen upon intake, you will be responsible for a minimum additional $10 per week drug screening fee until consistent negative results are received.)

PERSONAL INFORMATION

What is your motivating factor to abstain from substance use at this time:

What are your personal goals:

What do you hope to get out of your participation in the ARC program:

Are there any other areas of your life you need assistance for, please explain?

FINANCIAL INFORMATION

Person Responsible for Fees:

Responsible Party Phone Number:

Responsible Party Relationship:

Admission Fee: $550 (non-refundable; less the application fee)
Application Fee: $25-$100
Weekly Fee: $265 (due by accountability day)
Weekly Spending: $25-$50
Total Cost for Admission: $1,080 (includes admit fee + first 2 weeks of fees)

ADMISSION CRITERIA

Please check all that apply and note that we reserve the right to do a background check.

I am 18 years of age or olderI am free from alcohol or substance use for at least 72 hours and not in need of detoxificationI am willing to submit to a urine drug screen upon admissionI am free from any active warrants in this or any other countyI am free from any sexual chargesI am entering the facility voluntarily or court-mandated as approved to be at our facility by the courtI am medically stableI am willing to be assessed as medically stable and free of any illness or infection that requires isolation from othersI am able to have adequate control over your behavior and assessed to not be dangerous to yourself or othersI am willing to commit to active participation in all levels of the programI am able to meet personal needs (bathing, dressing, eating, etc...) without assistanceI am able to recognize that alcohol/drug use is a problem and express a desire to recover and change

RELEASE OF CONFIDENTIAL INFORMATION

If there is anyone who we will need to be able to contact/coordinate with regarding your intake process, please list them below and check which information we are allowed to discuss. Examples are probation, attorneys, a person financially responsible for your intake fees, or a family member/support person. If you do not list them here, we will not be able to discuss your intake process with them.

By digitally signing below, I am stating that my answers have been truthful and accurate and understand that I may be unsuccessfully discharged if found untruthful.

Digital Signature*:

Signing Date*: