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Henry County Women's Recovery Center
Application for submission into our 7-month live-in program
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PERSONAL HISTORY
Name
Your answer
Date of birth
MM
/
DD
/
YYYY
Social Security Number
Your answer
Phone Number
Your answer
Email address
Your answer
Current physical address
Your answer
Current mailing address (if different from physical)
Your answer
Current living situation
Own
Rent
Shelter
Other:
Clear selection
Desired move in date
MM
/
DD
/
YYYY
Current employment situation
Full-time employment
Part-time employment
Unemployed
Clear selection
Marital status
Married
Separated
Divorced
Widow
Partnership
Clear selection
Level of education completed
High School
Some College
Undergrad degree
Grad school
Other:
Clear selection
Are you a veteran?
Yes
No
Clear selection
Do you have a valid driver's license?
Yes
No
Clear selection
Do you have a car?
Yes
No
Clear selection
If yes, is it registered and insured?
Yes
No
Clear selection
Current treatment center?
Your answer
Expected discharge date
MM
/
DD
/
YYYY
Who referred you to us?
Your answer
SUBSTANCE USE HISTORY
Do you think you have a problem with alcohol?
Yes
No
Clear selection
If yes, please explain:
Your answer
Do you think you have a problem with drugs?
Yes
No
Clear selection
If yes, please explain:
Your answer
Primary addiction:
Your answer
Date of last use:
MM
/
DD
/
YYYY
List of drugs/alcohol you used addictively:
1) Name
Your answer
1a) Route
Your answer
1b) Age of first use
Your answer
1c) Date of last use
MM
/
DD
/
YYYY
2) Name
Your answer
2a) Route
Your answer
2b) Age of first use
Your answer
3c) Date of last use
MM
/
DD
/
YYYY
3) Name
Your answer
3a) Route
Your answer
3b) Age of first use
Your answer
3c) Date of last use
MM
/
DD
/
YYYY
4) Name
Your answer
4a) Route
Your answer
4b) Age of first use
Your answer
4c) Date of last use
MM
/
DD
/
YYYY
CHILDREN
Do you have children?
Yes
No
Clear selection
If yes, do you have custody of them?
Yes
No
Partial
Clear selection
If no, or partial, please explain
Your answer
If no, do you have visitation?
Yes
No
Clear selection
If you do have visitation, please explain. (Include if it is supervised or not, who supervises along with contact information, dates and times of scheduled visitation.)
Your answer
If yes, who will be caring for them while you are in the program. (Please include relationship and contact information.)
Your answer
EMERGENCY CONTACT(S)
These contacts cannot be currently residing with you.
1) Name of person
Your answer
1a) Relationship
Your answer
1b) Phone
Your answer
2) Name of person
Your answer
2a) Relationship
Your answer
2b) Phone
Your answer
3) Name of person
Your answer
3a) Relationship
Your answer
3b) Phone
Your answer
OTHER INFORMATION
Please list hobbies and special interests
Your answer
What would you say your best characteristics are?
Your answer
EMPLOYMENT HISTORY
Most recent employer
Your answer
Position
Your answer
Work schedule - (Full/Part-time, Shift work - 1st,2nd/3rd, Rotating schedule, Retail schedule)
Your answer
LEGAL HISTORY
Have you been arrested in the past 30 days?
Yes
No
Clear selection
If yes please explain.
Your answer
Probation officer
Your answer
Phone
Your answer
Are you mandated?
Yes
No
Clear selection
Are you experiencing legal problems?
Yes
No
Clear selection
If yes, please explain.
(i.e. court dates, warrants, restraining orders)
Your answer
MEDICAL HISTORY
Do you have a primary care physician?
Yes
No
Clear selection
Physician's name
Your answer
Physician's phone number
Your answer
Do you take any prescription medications
Yes
No
Clear selection
If yes, please list
Your answer
Do you have any medical conditions or allergies?
Yes
No
Clear selection
If yes, please explain
Your answer
Do you have any mental health diagnosis?
Yes
No
Clear selection
If yes, are you under the care of a mental health provider?
Yes
No
Clear selection
Name of provider
Your answer
Phone number of provider
Your answer
RECOVERY HISTORY
What recovery programs have you participated in in the past?
1) Name
Your answer
1a) Date
MM
/
DD
/
YYYY
2) Name
Your answer
2a) Date
MM
/
DD
/
YYYY
3) Name
Your answer
3a) Date
MM
/
DD
/
YYYY
Do you currently have a sponsor or Recovery Coach?
Yes
No
Clear selection
If yes, Name and what recovery program are they from
Your answer
Phone number of coach
Your answer
Do you have any other recognized addictions or disorders (i.e. eating disorder, cutting, sexual addictions)?
Yes
No
Clear selection
If yes, please explain
Your answer
How long have you been substance free/sober?
Your answer
What is the longest you have gone substance free/sober?
Your answer
How many previous recovery attempts/relapses have you had?
Your answer
Have you ever lived in a home shared by others (not family)?
Yes
No
Clear selection
Do you anticipate a problem with this?
Yes
No
Clear selection
If yes, please explain
Your answer
What is your goal for recovery?
Your answer
Please tell us anything else you want us to know about you and your story.
Your answer
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