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

    GENERAL INFORMATION

    Ethnicity:

    Are you currently experiencing any challenges with your identified orientation:

    Are you currently incarcerated?:

    What is your current residency?

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

    Have you ever experienced homelessness?:

    Visible tattoos?:

    Do you have a valid driver's license?:

    Do you have a vehicle:

    Do you have a State ID?:

    Do you have a Birth Certificate?:

    Do you have a Social Security Card?:

    Are you currently in an active relationship?:

    Legal Marital Status:

    Is DFCS Involved:use_label_element

    Do you owe child/spouse support:

    Highest level of completed education:

    Military experience:

    Have you previously applied for acceptance at ARC?:

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

    EMERGENCY CONTACT INFORMATION

    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?

    EMPLOYMENT STATUS

    Employment Status:

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

    LEGAL STATUS

    Mandating Party:

    Are you currently in any type of accountability court?:

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

    Are you currently on Misdemeanor Probation?:

    Are you currently on Felony Probation?:

    Are you currently on Parole?:

    Have you ever been incarcerated:

    Any Pending Cases:

    Have you ever been in prison:

    Have you ever been arrested for sex crimes:

    Have you ever been arrested for arson:

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

    HEALTH STATUS

    Rate your health:

    Any recent health changes:

    Are you pregnant:

    Do you smoke or use tobacco:

    Do you vape:

    Do you require any assistive technology?

    Do you use any complementary health approaches?

    Previous inpatient/hospitalizations due to psychiatric conditions?

    Family history of mental health conditions:

    Do you have any non substance addictive behaviors?

    If yes, please select all that apply:

    Have you experienced or witnessed any trauma in your lifetime?:

    If yes, please select all that apply:

    Attempted suicide:

    Current Suicidal thoughts:

    Acts of self-harm:

    Current thoughts of self-harm?

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

    Receive Government Assistance:

    Do you receive(check all that apply):

    Do you have medical insurance:

    Can you work:

    SUBSTANCE USE HISTORY

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

    Check all that apply:

    Are you addicted to drugs or alcohol:

    If yes, would you say drugs, alcohol, or both?:

    IV drug use:

    Family history of substance use:

    Previous treatment:

    Did you complete treatment:

    Additional Previous treatment:

    Additional Did you complete treatment:

    Attended AA or NA:

    (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

    FINANCIAL INFORMATION

    Admission Fee: $650 (non-refundable; less the application fee)
    Application Fee: $25-$100
    Weekly Fee: $275 (due by accountability day)
    Weekly Spending: $25-$50
    Total Cost for Admission: $1,130 (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 older
    I am free from alcohol or substance use for at least 72 hours and not in need of detoxification
    I am willing to submit to a urine drug screen upon admission
    I am free from any active warrants in this or any other county
    I am free from any sexual charges
    I am entering the facility voluntarily or court-mandated as approved to be at our facility by the court
    I am medically stable
    I am willing to be assessed as medically stable and free of any illness or infection that requires isolation from others
    I am able to have adequate control over your behavior and assessed to not be dangerous to yourself or others
    I am willing to commit to active participation in all levels of the program
    I am able to meet personal needs (bathing, dressing, eating, etc...) without assistance
    I 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)







     

     

    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.