RECOVERY APPLICATION The Foundry Ministries

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Prosper Giles Lindsey
6 years ago
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1 RECOVERY APPLICATION The Foundry Ministries PERSONAL FIRST NAME MIDDLE NAME LAST NAME LAST PHYSICAL STREET ADDRESS CITY STATE ZIP CELL ADDRESS DEMOGRAPHICS GENDER ETHNICITY AGE

2 MARITAL STATUS SINGLE MARRIED DIVORCED SEPARATED WIDOWED COMMON LAW WHAT IS THE HIGHEST LEVEL OF EDUCATION COMPLETED? LESS THAN HIGH SCHOOL HIGH SCHOOL GED SOME COLLEGE COLLEGE DEGREE MASTERS DEGREE NONE CONTACT INFORMATION PLEASE LIST CONTACT INFORMATION FOR TWO INDIVIDUALS. CONTACT ONE RELATIONSHIP (CHILD, MOTHER, ETC.) FULL NAME ADDRESS CONTACT TWO RELATIONSHIP (CHILD, MOTHER, ETC.) FULL NAME ADDRESS

3 BACKGROUND INFORMATION THE FOLLOWING INFORMATION IS COLLECTED TO AID THE FOUNDRY MINISTRIES IN RAISING FUNDS TO PROVIDE THE SERVICES AND PROGRAMS NECESSARY TO HELP RESHAPE LIVES. THIS INFORMATION IS NOT A CONDITION OF THE APPROVAL OF YOUR APPLICATION. CHURCH AFFILIATION LAST CHURCH ATTENDED NAME HAVE YOU OR ANYONE LIVING IN YOUR HOUSEHOLD SERVED IN THE MILITARY? YES NO ARE YOU OR ANYONE LIVING IN YOUR HOUSEHOLD SERVING AS ACTIVE MILITARY? YES NO HOUSING RENT OWN HUD/SECTION 8 LEASE/PURCHASE OTHER LEGAL HAVE YOU EVER BEEN TO JAIL OR PRISON? ARE YOU CURRENTLY INCARCERATED? HAVE YOU EVER BEEN CONVICTED OF A SEXUAL OFFENSE OR CURRENTLY HAVE SEXUAL CHARGES PENDING? ARE YOU REQUIRED BY A COURT OFFICIAL TO COMPLETE THE FOUNDRY S RECOVERY PROGRAM?

4 IF YES, COURT OFFICIAL S NAME ADDRESS CITY STATE ZIP CHARGE COUNTY COURT DATE ARE YOU PRESENTLY ON: PROBATION PAROLE TASC COURT REFERRAL COMMUNITY CORRECTIONS HOW DO YOU REPORT? HOW OFTEN DO YOU REPORT? DO YOU HAVE TO REPORT FOR URINE SCREENS? SUPERVISOR S NAME FAX ADDRESS CITY STATE ZIP

5 MEDICAL HISTORY THE FOUNDRY IS NOT A DETOX FACILITY. IF YOU ARRIVE AT THE FOUNDRY NEEDING DETOXIFICATION, YOU WILL BE REFUSED ADMITTANCE. DO YOU HAVE ANY PROBLEMS WITH ANY OF THE FOLLOWING CONDITIONS? (CHECK ALL THAT APPLY) HIGH BLOOD PRESSURE DIABETES HEART CONDITION OPEN SORES EPILEPSY HIC/AIDS HEPATISIS C TUBERCULOSIS BACK PROBLEMS HIP/KNEE REPLACEMENT OTHER HAVE YOU EVER BEEN UNDER PSYCHIATRIC CARE? WHEN? WHY? DIAGNOSIS DOCTOR S NAME LIST ANY ALLERGIES: (FOOD OR MEDICATION)

6 DO YOU HAVE CURRENT PROBLEMS OR ANY HISTORY WITH: (CHECK ALL THAT APPLY) DEPRESSION BIPOLAR DISORDER BORDERLINE PERSONALITY ANTISOCAIL PERSONALITY DISORDER ANY TYPE OF BRAIN INJURY DEMENTIA PARANOIA SCHIZOPHRENIA PSYCHOTIC DISORDER OTHER ARE YOU PREGNANT? (IF APPLICABLE) HOW MANY MONTHS? LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING. MEDICATION DOSE RX DATE QUANTITY PHYSICIAN REASON PRESCRIBED MEDICATION DOSE RX DATE QUANTITY PHYSICIAN REASON PRESCRIBED MEDICATION DOSE RX DATE QUANTITY PHYSICIAN REASON PRESCRIBED

7 ARE YOU DISABLED OR HANDICAPPED TO THE EXTENT THAT YOU WILL BE UNABLE TO STAND ON YOUR FEET FOR EIGHT HOURS A DAY FOR WORK RELATED TASKS? DO YOU HAVE SPECIAL DIETARY NEEDS? SUBSTANCE ABUSE/REHAB HISTORY PRIMARY DRUG OF CHOICE SECONDARY DRUG OF CHOICE OTHER DRUGS CURRENTLY USED: ADDERALL ALCOHOL BARBITUATES BATH SALT COCAINE CRACK DILAUDID DXM ECSTACY GHB HEROIN HYDROCODONE INHALANTS KLONOPIN LSD LUBRIUM MARIJUANA MARIJUANA (SYNTHETIC) METH METHADONE MORPHINE OPIATES PSYCHOTROPIC ROXICET SUBOXONE VALIUM XANAX OTHER

8 HAVE YOU PREVIOUSLY ATTENDED ANY SUBSTANCE ABUSE PROGRAMS? NAME DATE PROGRAM STARTED DID YOU COMPLETE THE PROGRAM? CIRCUMSTANCES OF DEPARTURE: HAVE YOU ATTENDED MORE THAN ONE SUBSTANCE ABUSE PROGRAM? NAME DATE PROGRAM STARTED DID YOU COMPLETE THE PROGRAM? IF NO, DESCRIBE THE CIRCUMSTANCES OF DEPARTURE HAVE YOU ATTENDED MORE THAN ONE SUBSTANCE ABUSE PROGRAM? NAME DATE PROGRAM STARTED: DID YOU COMPLETE THE PROGRAM? IF NO, DESCRIBE THE CIRCUMSTANCES OF DEPARTURE

9 WORK HISTORY/JOB SKILLS TYPES OF JOBS WORKED (EXAMPLE: CONSTRUCTION, CLERICAL, AUTO, DAY LABOR, RESTAURANT, SALES, RETAIL, ETC.) DO YOU HAVE A VALID DRIVERS LICENSE? HAVE YOU HAD A DUI IN THE PAST 10 YEARS? PLEASE CHECK ANY OF THE FOLLOWING PROFESSIONS YOU HAVE EXPERIENCE IN: ADMINISTRATION COOK CARPENTRY FARMING MECHANICAL PLUMBING ELECTRICIAN TELEMARKETING DENTAL MANAGEMENT HOMELESSNESS HAVE YOU EVER BEEN HOMELESS? REASON YOU WERE HOMELESS: UMEMPLOYED ADDICTIONS DOMESTIC PROBLEMS PSYCHIATRIC PROBLEMS LEGAL PROBLEMS MEDICAL PROBLEMS HOW LONG WERE YOU HOMELESS? HOW MANY INDIVIDUAL TIMES HAVE YOU BEEN HOMELESS?

10 DO YOU CURRENTLY LIVE AT A RESIDENCE THAT YOU SOLELY OR JOINTLY RENT OR OWN? HOW DID YOU HEAR ABOUT THE FOUNDRY MINISTRIES? APPLICANT SIGNATURE STAFF SIGNATURE DATE

Program Application. Name: SSN: Address: City: State: Zip: Phone: Date of Birth: Age: Occupation: Highest Grade Completed/College/Degree:

Program Application. Name: SSN: Address: City: State: Zip: Phone: Date of Birth: Age: Occupation: Highest Grade Completed/College/Degree: DATE: I. PERSONAL INFORMATION Name: SSN: Address: City: State: Zip: Phone: Date of Birth: Age: Occupation: Highest Grade Completed/College/Degree: Other skills/training: What tools can you use: Farm or