Please note: items with * are required and phone numbers must be 10 digits.

    GENERAL INFORMATION

    Full Legal Name*:

    Pronouns:

    If you prefer to go by another name, or have a nickname, please provide it here:

    Full Social Security Number*:

    Birth Date*:

    Age*:

    Race:

    Ethnicity:HispanicNon-Hispanic

    Gender:

    Sexual Orientation:

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

    If yes, please explain:

    Phone Number*:

    Email Address*:

    GDC or EF Number:

    Are you currently incarcerated?:YesNo

    If yes, where:

    What is your current residency?

    (if you are incarcerated what was your living arrangement before incarceration): Own HomeParentsRelativeFriendDetoxIncarceratedHomelessOther

    If other, please explain:

    Address:

    Have you ever experienced homelessness?:YesNo

    If yes, what did this look like for you?:

    Visible tattoos?:YesNo

    If yes, please describe:

    Do you have a valid driver's license?: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

    Do you have a Birth Certificate?:YesNo

    Do you have a Social Security Card?:YesNo

    Are you currently in an active relationship?:YesNo

    If yes, with who?

    Legal Marital Status:SingleNever MarriedMarriedSeparatedDivorcedWidowed

    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:

    Have you previously applied for acceptance at ARC?:YesNo

    If yes, when?

    Do you know any current or previous residents or staff of ARC?:YesNo

    If yes, who?

    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?

    Do you currently have legal authority to make decisions for yourself, or is there someone else who has been granted power of attorney to make decisions on your behalf?YesNo

    If no, please explain::

    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:

    Are you currently able to work a full time job which is 30-590 hours per week?:YesNo

    If no, explain:

    LEGAL STATUS

    Referred By:

    Mandating Party:ProbationParoleAccountabilityOther

    Are you currently in any type of accountability court?:YesNo

    If yes, which one and what county?:

    Are you court ordered to complete a THOR approved program?:YesNoUnsure

    Are you currently on Misdemeanor Probation?:YesNo

    Are you currently on Felony Probation?:YesNo

    Are you currently on Parole?:YesNo

    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 in your lifetime?: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:

    Are you addicted to drugs or alcohol:YesNo

    If yes, would you say drugs, alcohol, or both?: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 not?

    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 not?

    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.

    TO PROVIDE OR RECEIVE FROM:

    PURPOSE OF THE USE & DISCLOSURE OF:
    (check all that apply)

    INFORMATION TO BE DISCLOSED:
    (check all that apply)

    Name:
    Relationship:
    Phone:

    Coordination of CareLegal RequestFamilyCase PlanOther

    If Other, please specify:

    Recovery PlanningIntake ProgressMedical RecordsFinancialOther

    If Other, please specify:

    Name:
    Relationship:
    Phone:

    Coordination of CareLegal RequestFamilyCase PlanOther

    If Other, please specify:

    Recovery PlanningIntake ProgressMedical RecordsFinancialOther

    If Other, please specify:

    Name:
    Relationship:
    Phone:

    Coordination of CareLegal RequestFamilyCase PlanOther

    If Other, please specify:

    Recovery PlanningIntake ProgressMedical RecordsFinancialOther

    If Other, please specify:

     

     

    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*: