Online Application Name (First, Middle, Last)(required) Race/Ethnicity(required) Gender(required) Mailing Address(required) City, State, Zip(required) County(required) Email Address Location of Current Residence (give details)(required) Phone Number(required) Level of Current Supervision(required) Home Confinement Probation Bond Incarcerated Other If Other, explain(required) Supervisor (i.e. Probation/Home Confinement Officer, Counselor, Attorney, etc.)(required) Counselor/Attorney(required) Sentencing Judge(required) Emergency Contact (Full Name)(required) Phone Number (___-__-____)(required) Relation(required) Mailing Address(required) City, State, Zip(required) Driver License/ID Information (Type, ID#)(required) Social Security Number (___-__-____)(required) Date of Birth (mm/dd/yyyy)(required) Birth Certificate(required) Yes No Social Security Card Yes No Medical Card Yes No EBT Snap Yes No 1. Do you have a current felony conviction for which you are being referred? (This must be your CURRENT charge)(required) Yes No Explain(required) 2. List previous legal charges of which you have been convicted(required) 3. List and describe any and all past convictions that are violent in nature:(required) 4. What is your Primary drug of choice? Second? Third?(required) 5. Describe history of use (first use, last use, amount/frequency, route of administration)(required) 6. Describe your longest amount of sobriety (incarcerated vs unsupervised, age, length of time, medically assisted)(required) 7. List and describe prior substance abuse treatment(required) 8. Personal sobriety date(required) 9. Are you currently experiencing any symptoms of withdrawal?(required) Yes No 10. Please list and describe any significant medical issues at this time(required) 11. Please list any current medications(required) 12. Please list any medications that you have used /have had prescribed in the past 30 days(required) 13. Have you ever been diagnosed with a mental health diagnosis?(required) Yes No If yes, describe past and present symptoms pertaining to each reported diagnosis(required) 14. If you have ever received mental health treatment, please list and describe. (where, diagnosis, when, duration, prescriptions provided)(required) 15. If you have ever experienced thoughts, plans, or taken action to hurt yourself or someone else, please explain.(required) 16. Please explain your motivation for treatment at this time(required) 17. What help do you believe you need at this point in your recovery?(required) 18. Why are you interested in receiving treatment from Recovery Group of Southern WV and/or Directions of Southern Regional Day Report Center?(required) 19. Are you committed to participating in a residential treatment program for 8 to 12 months? Explain(required) 20. Do you have a sponsor, home group, or a connection to a greater recovery community?(required) 21. Please describe any form of support (mental, emotional, financial, spiritual) that you will have at this time and any support you believe you will have after completing the program(required) 22. Do you agree to participate in a Christian based community?(required) Yes No 23. Are you spiritual? Explain(required) 24. Occupations(required) 25. Do you have a source of income? (i.e. Pension, Retirement, Disability, SSI, etc.)(required) Yes No Details(required) 26. Are you a Veteran?(required) Yes No Details(required) Submit Δ Share this:TwitterFacebookLike this:Like Loading...
