Summit Recovery Housing, LLC

APPLICATION FOR ADMISSION TO RECOVERY HOUSE

NAME___________________________________________
DATE OF INTERVIEW_________________________________
REFERRING AGENCY_________________________________
DOB_____/_____/______ SSN________-________-_______
REQUESTED DATE OF ADMISSION________________________
PAST MEDICAL HISTORY_________________________________________

__________________________________________________________
MEDICATION_________________________________________________
DRUG/ALCOHOL HISTORY (INCLUDE DRUG(S) , AMOUNT, ROUTE
OF ADMINISTRATION, HOW LONG, PAST TREATMENT)

____________________________________________________________
_______________________________________________
CLEAN DATE_________IN AFTERCARE? Yes / No WHERE_________________
COUNSELORS NAME________________________
LEGAL ISSUES________________________________________________
__________________________________________________________
EVER ARRESTED OF ARSON?
YES
NO
EVER ARRESTED OF SEXUAL ASSAULT
YES NO
N CASE OF EMERGENCY, LIST CONTACT PERSON (INCLUDE RELATIONSHIP, TELEPHONE
NUMBER, & ADDRESS)

___________________________________________________________
___________________________________________________________
EMPLOYER IMFORMATION
COMPANY NAME:_______________________CONTACT NAME____________
PHONE:___________________________WEEKLY INCOME______________