Independence Again

Intake / Application for participation in Therapeutic Sober Living Community

Name of Person Completing the application: ______________________________________

Relationship and Contact Info to applicant: ________________________________________

Date: __________________________  Desired Admit Date: __________________________

Program Seeking: Circle Men -or-  Women    Circle Sober Living -or-  *Recovery Collective House -or-  **MAT

*Sober Living: Residents participate in a Therapeutic Sober Living Program within a communal living environment. Staff provide supervision to ensure adherence to rules and support skill development based on individual needs. The board of directors oversees policy and procedure implementation, while staff ensure compliance. *Recovery Collective House: Residents democratically manage the house under supervision, electing officers for defined terms. Our staff facilitate and maintain this democratic process to ensure its smooth operation. *Medically Assisted Treatment (MAT) Program: Admission to the MAT program requires pre-approval. Starting MAT medication without program admission may result in immediate discharge or a mandatory transfer to another treatment facility. Due to limited availability, applicants are encouraged to apply well in advance of their anticipated need.

What is going on today to motivate seeking help with Independence Again: _____________________________________________________

_________________________________________________________________________________________________________________

Is the resident able and willing to follow the rules of the house, including but are not limited to regular meetings, curfew, weekly dues, working 32+ hours weekly, educational classes, chores, group sessions, and compliance with medical and mental health if needed? Yes -or - No         

Resident Information: First: ____________________________ Middle: ___________________ Last: _______________________________

Maden/Aliases: ____________________________________ Nickname: ____________________________ Birth Gender: Male - or - Female 

TOMIS No. _______________________ Full Address: _____________________________________________________________________

Phone #: ___________________________________ E-mail: ________________________________________________________________

DOB (mm/dd/yyyy): ______________________  Age: _____________ SS#: _____________________________ Speak English: Yes -or - No

Driver’s License and/or State ID#: ______________________________________ Marital Status: ___________________________________

Race: ___________________________    Nationality: ________________________________   Circle Hispanic Origin or Not Hispanic Origin 

Preferred Language: ________________   Preferred Religion: ________________  

Emergency Contact Information: Person we can call at this time, Name: ___________________________ Phone: ____________________

Name: ________________________ Relationship: ________________ Email: _______________________ Phone: ____________________

Dr’s Name: ________________________________________________ Email: _______________________ Phone: ____________________

MH Provider: ______________________________________________ Email: _______________________ Phone: ____________________

Use History: Most severe Drug(s) of Choice ______________________ Second _______________________ Third ____________________

1st: date first used if within a year / age of 1st use LU: date last used if within a year / age of last use don’t leave blanks put NA if never used

Number of days abstained from all substances in the last 30 days: ________

If you've been in jail/prison, also include how many days you were drug-free before you got arrested this time: ________

Use Policy: If a resident uses alcohol, illegal drugs, or prescription drugs without a valid approved prescription while in the Independence Again program, they need to follow all the therapeutic recommended treatments to stay in the program. Monitoring: Our staff will observe residents' behaviors and occasionally test them for drug use to keep track of potential risks.Compliance: Residents must follow all the rules and guidelines of the program.Note: The drug test isn't the only way we gauge a resident's progress. It's just one of the tools we use to make sure they're getting the right level of care.  Agreement: Do you understand and agree with these terms? Yes -or - No

Will resident be prescribed or anticipate being prescribed any of the following medications: Circle all that apply -  Acamprosate; Antabuse (Disulfiram);  Buprenorphine (Probuphine);  Buprenorphine with Naloxone (Suboxone, Subutex, Zubsolv, Bunavail);  Champix;  Nicotine Patches, Microtab,  Gabapentin (Neurontin, Horizant, Gralise);  Methadone: Pregabalin (Lyrica);  Varenicline (Chantix); Vivitrol;  Wellbutrin (Bupropion HCl, Wellbutrin SR, Wellbutrin XL, Zyban, Aplenzin, Fortivo XL, or Zyban)

List all medications: _______________________________________________________________________________________________

Consider residents' physical health to be in:         Circle One         Great        Good        Fair        Poor        Critical Poor Health 

If an applicant arrives with an undisclosed limitation that we are unable to monitor or are unaware of, we reserve the right to decline admission or discharge as a result. Please indicate if the resident is able to engage in the following:

Work 32+ hours each week Yes -or - No                         Get onto a top bunk of a bunk bed  Yes -or - No (*we may use a bunk bed)

Walk a quarter mile assistance-free  Yes -or - No                   Complete household chores without assistance  Yes -or - No 

Lift or carry up to ten pounds  Yes -or - No                   Walk up a flight of steps without resisting Yes -or - No 

Seeking or on Disability Yes -or - No                           Barriers to attending community recovery meetings (i.e. NA/AA) Yes -or - No 

Resident has been screened for PTSD  Yes -or - No           Resident has been screened for a Traumatic Brain Injury (TBI)  Yes -or - No           

TB Test Results: __________________________________        Last TB test Date: _________________________________________________

List all medical issues resident may seek treatment for in the next year? _______________________________________________________

When was the last time the resident attempted suicide; please explaine? _______________________________________________________

How many 12-Step Recovery Meetings has the resident attended in the last 30 days: #__________

Recovery and Treatment History for resident: # of times resident has attended treatment in their life: Co-Occurring Treatment #__________

Substance Use Treatment: #__________   Mental Health Treatment: #__________ Please list all places resident has attended treatment in the past four (4) years and when (i.e., Inpatient, Detox, Partial Hospitalization, Substance Abuse IOP, Substance Abuse LIOP, continuing Care): ____________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

Education: Last Grade Completed: ________________  Reading/writing level or higher ____________

Family Information: # of Children under 18 years of age: #__________  Over 18 years of age: #__________

Number of people supported by residents income: #__________ Who, relationship: ______________________________________________

Housing and Income Information: Is resident currently sleeping in a place not designed for human habitation?  Yes -or - No  

Is resident able to pay the entry fee upon admit.  Yes -or - No  (Based on program enrolled in cost is between $320-$375)

Is resident or loved one able to pay the weekly rent (on Sundays) till resident is employed; Yes -or - No (program enrollment determines rent)

Is resident employable in the U.S.A? If no please explain: ___________________________________________________________________

List any financial commitments that would make it hard for the resident to pay their bills? __________________________________________

Military: No Affiliation -or- Served -or- Dependent   What Branch: __________________________   # of Diployments: ___________________

Combat Theaters: __________________________________________________________________________________________________

DischargeType: Circle One: Active Service        Honorable        Under Honorable Conditions        Under other than Honorable Conditions        

Bad Conduct        Dishonorable        Uncharacterized Explain if less than honorable: _________________________________________

Financial Assistance Options: Independence Again offers various ways to help with your expenses. These include grant funding, state funding, or sponsorship, depending on availability. Here's what you need to know: RHP funding is for court-ordered residents (not on furlough) and must be approved in advance by the RHP Housing coordinator. TN ARP funding requires participation in treatment planning and case management. It's short-term and involves extra activities. Sponsorship means engaging in activities and services provided by the sponsoring church or business. Remember: Each program is seen as a privilege and may need approval before you can join. It's important to understand that none of these funding options cover your entire stay with Independence Again. This is intentional. It's meant to help you learn budgeting and independent living skills. Do you agree and understand? Yes -or - No

Transportation Fee: Public transportation through UCHRA (Phone: 931-372-8000) is the main mode of travel. Costs range from $1 to $2.50 for a one-way trip and are the responsibility of the resident. Staff transportation is available on a case-by-case basis, depending on availability. I agree and understand: Yes -or - No

Rent: Falling behind on rent payments may result in dismissal from the Independence Again program. Rent payments help maintain the facility and provide quality care to residents. If I face financial difficulties, I will promptly notify staff and seek help from friends, family, or local resources. I acknowledge the policies FS-001 and FA-001 regarding this issue. I agree and understand: Yes -or - No

How long do you anticipate it will take to achieve your goals and live independently outside our transitional living community? Estimate: ________

Legal: Current involvement in the legal system in any way Yes -or - No   If incarcerated, where? ____________________________________

Will resident have: External supervision? Yes -or - No Pending legal:  Yes -or - No If so; in what court(s)? ____________________________

# of Arrest in Lifetime: _______________   # of arrests in last 12 months: _______________    # of Consecutive Days in Jail ______________

Last Date of Conviction of DUI: ___________  County Convicted in: ______________________  DUI Judge: __________________________

Any pending charges or a conviction for a: Sex Crime  Yes -or - No    Violent Crime  Yes -or - No   Child Endangerment  Yes -or - No 

Please Explain: ___________________________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

List all criminal charges that have been brought against the resident and the outcome: ____________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

How invested in recovery is the resident? On a scale of 1 – 10 (1 being someone wants me to do it and 10 being I will not let anything stand in my way; please explain) 

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

What does the resident hope/expect to get out of being in the program? ________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

What goals can the staff and other members of Independence Again help with? _________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

Additional comments and concerns: ____________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

Important Notice: Our Therapeutic Sober Living program requires a minimum commitment of six (6) months, with duration varying based on individual progress. The length of stay in our Recovery Collective House is determined on a case-by-case basis. Participation in our Medically Assisted Treatment (MAT) program mandates adherence to a titrated dosage and adherence to the agreed-upon treatment plan for continued enrollment. Keep in mind that your journey through the program will vary in length and your patience, honesty, open-mindedness, and willingness serve as indicators of the duration needed. Please indicate your understanding and agreement: Yes -or - No

To apply and inquire, please send your application and any questions to App@IndependenceAgain.org or fax them to 931-401-4670. For urgent requests needing immediate attention (within ten (10) days), contact our staff after submitting your application to expedite the review process. Reach us at 888-417-0233 and follow the prompts to connect with our program staff.

Staff check the email and fax multiple times a week; however, we do not check daily, on weekends, or during holidays.

Independence Again provides the following essentials for the duration of your stay in our program (upon request): Twin size bed, Twin size mattress, Twin sheet set, Blanket, Pillow, Towel, Washcloth, Up to 2 rolls of toilet paper weekly or other required program items.

We suggest bringing the following items (if possible): Social Security Card, Birth Certificate, Photo ID, Limited money for necessities only, Weather-appropriate clothing for a week (laundry access provided), Hangers, Alcohol-free hygiene products, Laundry pods, Cloth or collapsable Laundry basket, Pajamas, Alarm clock, Limited food (grocery store access provided), Shower slippers, Hair accessories, Tobacco products or vape (limited), Limited photos of loved ones, Limited creature comforts, or Books for recreational reading. (Items must fit under half of your bed) Cellular phone (once approved)

Please note: Space is limited; excess clothing or items must be mailed/given to family or donated. Mark/label all items not being left upon program completion; unlabeled items will be left behind. Remember, any items left behind after program completion will be immediately donated. All mail will be returned to sender; we do not hold mail after a resident leaves. We are not responsible for personal items at any time. Please indicate your understanding and agreement: Yes -or - No

___________________________________________________  ________________         ____________________________________________________  _________________

Signature of applicant or supportive family/peer:              Date:                Approved by Independence Again Staff/Volunteer:              Date:

(by signing, resident agree to the rules)                                        (Approval is confirmed, condition on bed availability upon scheduled arrival)