Client Assessment for AdmissionScreening Date:(Required) MM slash DD slash YYYY Full Legal Name(Required)DOB(Required) MM slash DD slash YYYY Phone(Required)Email(Required) Referring Agency or Self-Referral:(Required)Date of Release:(Required) MM slash DD slash YYYY List Child(ren) (if applicable) with age (see women & children section):Have you ever been a client of Foundations to Freedom? Yes No If Yes, when?Why did you discharge?Where are you currently residing?(Required)What is the reason for seeking recovery housing?Do you have a substance use concern with either alcohol and/or other drugs? If so, are you willing to work towards sustained recovery? Yes No What is your substance use history?How long?Last day that you used:What substances:Are you in need of detox? Yes No Are you able to pass a drug test and breathalyzer? Yes No Are you a military veteran Yes No Do you consent to random/supervised drug and alcohol testing during your stay? Yes No Can you provide a copy of a government-issued ID verifying your name and age? Yes No If accepted as a Foundations client, do you understand if you use a substance while a client, you may face expulsion from Foundations? Yes No Are you willing to provide Foundations with an emergency contact? Yes No Do you understand that all client personal property, vehicle, and person will be searched upon arrival and at any time during your stay? Yes No Are you able to manage basic daily living activities on your own (e.g., bathing, dressing, eating, evacuating the home during emergencies) Yes No Once a Foundations client, do you understand that you may not take any Schedule II medications unless under dire medical emergencies as determined by a licensed physician, approved by Foundations staff, and taken while not residing at Foundations property (i.e. Emergency Room or surgery) Yes No Do you agree to adhere to all Foundations house rules and act in a good manner while a Foundations client (this includes: attending mutual support groups regularly, adhering to the support groups recommendations for recovery, and attending weekly Foundations house meetings) Yes No Are you currently on probation, parole, or a fugitive? Yes No To your knowledge, do you have an open warrant for arrest in any state (A warrant search will be performed on all potential clients)? Yes No Are you registered as a sexual offender or predator? Yes No Have you been convicted of child abuse or child neglect? Yes No Are you currently enrolled in a Medication-Assisted Treatment program with a licensed physician? Yes No If so, what is the MAT protocol are you currently participating?Do you have any physical limitations? (Please list)Have you ever been diagnosed or suspected that you have a mental health condition?Does client agree to keep medications confidential and not disclose your medication to other clients? Yes No Are you now on or have you ever been prescribed mental health medication? Yes No Are you currently employed or in school? Yes No If not, are you able to work? Yes No Responsible for weekly fees? Self- Pay Family Agency If other than self-pay, who will pay fees?Contact information:Fees: Intake Fee (all) - $60.00, Weekly Fee (single male/female) - $180.00 Weekly Fee (woman with child(ren) - $200.00 While a client, do you agree to use Customer Relationship Management software on your mobile device, that requires GPS/location information, opt to always leave your location on, and to never disable the software? Yes No Do you have any questions for Foundations?List medications you are currently taking.The correctness of the information(Required) Do you attest that all the above information is true, and is correct to the best of your knowledge, and you also understand that any falsified information on this questionnaire is grounds for non-entry and/or your future dismissal from Foundations? I, hereby being bound and fully aware, acknowledge and agree that all the above information is true, and is correct to the best of my knowledge, and I also understand that any falsified information on this questionnaire is grounds for non-entry and/or my future dismissal from Foundations.(Required)Signature/Name
