First name: Last name: Date of birth: Social Security Number: Phone Number: Emergency contact (Name, Address, City, State, Phone, Relationship to you): Current TX Center or Correctional Institute: Center or Institute Phone: Center or Institute Contact Name: Projected Discharge Date: Past Treatment Programs (City, State, Counselor, Date): Have you ever lived in a Sober House or a Half-way House? YesNo If yes, which state? ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Date residence began: Date residence ended: Substance use history (what, when, age started, how long): IV Usage: YesNo Drug of choice: Last use of ANYTHING MIND ALTERING: What 12-Step Program are you attending? Do you have a sponsor? YesNo Sponsor’s name: Sponsor’s Phone Number: What is your source of income? Employer: Employer’s phone number: Supervisor’s name: Employment start date: Income: When do you get paid? WeeklyBiweeklyMonthlyOther Have you been arrested for a Felony? YesNo If yes, please explain and list charges: Are you currently on Probation or Parole? YesNo If yes, how long? Probation officer: Probation officer’s phone number: Do you have pending legal matters? YesNo If yes, please explain and list charges: Current medication you take (and dosage): Are you participating in Medically Assisted Recovery? YesNo What do you take? What are your plans to stop Medically Assisted Recovery, and is it part of your discharge summary and aftercare plan? Please attach your treatment plan: How did you hear about Kimmi’s Casas? Why do you think Sober Living is a good fit for you? Any additional notes?
First name:
Last name:
Date of birth:
Social Security Number:
Phone Number:
Emergency contact (Name, Address, City, State, Phone, Relationship to you):
Current TX Center or Correctional Institute:
Center or Institute Phone:
Center or Institute Contact Name:
Projected Discharge Date:
Past Treatment Programs (City, State, Counselor, Date):
Have you ever lived in a Sober House or a Half-way House? YesNo
If yes, which state? ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY
Date residence began:
Date residence ended:
Substance use history (what, when, age started, how long):
IV Usage: YesNo
Drug of choice:
Last use of ANYTHING MIND ALTERING:
What 12-Step Program are you attending?
Do you have a sponsor? YesNo
Sponsor’s name:
Sponsor’s Phone Number:
What is your source of income?
Employer:
Employer’s phone number:
Supervisor’s name:
Employment start date:
Income:
When do you get paid? WeeklyBiweeklyMonthlyOther
Have you been arrested for a Felony? YesNo
If yes, please explain and list charges:
Are you currently on Probation or Parole? YesNo
If yes, how long?
Probation officer:
Probation officer’s phone number:
Do you have pending legal matters? YesNo
Current medication you take (and dosage):
Are you participating in Medically Assisted Recovery? YesNo
What do you take?
What are your plans to stop Medically Assisted Recovery, and is it part of your discharge summary and aftercare plan?
Please attach your treatment plan:
How did you hear about Kimmi’s Casas?
Why do you think Sober Living is a good fit for you?
Any additional notes?