Apply

Full Name*
Date Of Birth*
Age*
Gender*
MaleFemale Phone Number*
Email*
Name of your Insurance Provider*
Social Security Number*
Are you currently in treatment? If so, where?*
Name of Primary Counselor or Case Manager*
Primary Counselor or Case Manager’s email*
Primary Counselor or Case Manager’s phone number (and extension)*
What is your drug(s) of choice?*
When was the last time you used drugs or alcohol?*
What is your current Recovery Plan?*
Have you been in recovery in the past? If so, what was the longest length of sobriety you have sustained?*
Have you ever lived in a Recovery House before? If so, when and where?*
List of prescription medication(s)*
Do you have any co-occurring disorders, such as behavioral or mental health illnesses? If so, what diagnosis(s) have you been given?*
Do you have any communicable diseases? If so, what? (This would not prevent you from being accepted into the program, but we do have to know).*
Are you currently on Probation, Parole, Drug Court, or have any charges pending? If so, for what?*
Do you have any felonies? If so, what was the offense and when did this occur?*
Have you ever been accused of or convicted of any violent crimes? If so, what happened?*
Have you ever been convicted of arson?*
Have you ever been accused of or convicted of a sex crime or are you on Megan’s Law?*
Have you ever had any suicide attempts or struggle with cutting? If so, when was the most recent occurrence?*
Do you struggle with any Eating Disorders?* Do you have any physical limitations or health issues we need to be aware of?
If accepted, do you have the finances or funding needed to move in?*
Name of person paying move-in fee (Payee)*
Payee Contact Information (Phone number)*
Will you be attending outpatient services while living at Phoenix Recovery? (PHP, IOP, OP, etc...) If so, where? *
What is the best way to currently contact you? (Through your Case Manager/Primary Counselor OR you directly)*
Requested Move-In Date* How did you hear about Phoenix Recovery?