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Phoenix Recovery House Application
Thank You for your Interest in the Phoenix Recovery House.
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Referral Process
Referrals will be taken each day. The Advisory committee will review applications each Wednesday. Once applications are reviewed candidates will be contacted to do an interview. After the interview candidates that are a selected to our program will be contacted.
The Phoenix Recovery House is a place where women  can get the help and support they need to live a healthy, productive sober life. The Recovery House will offer a unique approach to women in recovery. We know that maintaining sobriety is an ongoing struggle for many. We have developed this 12 month program that incorporates the 12-steps to not only focus on sobriety but also help women overcome past trauma and provide them with the life skills they need to succeed. A case manager will work with each woman to help link them to clinical services. A live-in house manager will ensure daily schedules are followed and that everything runs smoothly.Each woman will work with their case manager to define goals and develop the tools they need to achieve those goals. We will offer weekly classes focused on life skills. Did you read this section? *
Full Name *
Date of Referral (today's date) *
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Date of Birth *
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Phone Number *
Email *
Do you have valid Drivers license or ID *
Marital Status *
Do you have children? *
If yes, How Many children do you have and what are their ages?
Level of education *
Who referred you? *
Current Treatment facility: *
Primary Counselor: *
Expected Discharge date: *
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RECOVERY INFORMATION
Do you have a sponsor? *
Primary Addiction *
Date of last use *
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List Drugs you have used addictively and date of last use *
Any other recognized addictions or disorders (i.e. Eating disorder, self-harm)? *
If yes, please describe:
How long have you been sober? *
What is the longest you have gone substance free? *
How many previous recovery attempts/relapses have you had? *
Have you ever lived in a home shared by other people? *
Are you on any maintenance programs, and if so, which? Are you interested in being on a maintenance program? *
What is your main goal at this time? *
MEDICAL INFORMATION
This information will be used to collect information to make a personalized recovery plan. All medications will be kept in a lock box.
Do you have any food allergies or restrictions? *
Do you take any prescription medications? *
If yes, Please list:
Do you have any medical conditions or allergies? *
Do you have a mental health Diagnosis? *
If yes, Please explain
Have you ever experienced suicidal ideations, attempts, or received in-patient treatment for self-harming/? *
LEGAL INFORMATION
This information will be used to collect information to make a personalized recovery plan.
Do you have any pending legal matters? *
Have you ever been convicted of a felony? *
If yes please explain
Are you required to register as a sex offender? *
Are you currently on parole or probation? *
Parole or probation officer? *
Are you experiencing legal problems ( i.e. Court dates, warrants, active restraining orders)? *
OTHER INFORMATION
This information will be used to collect information to make a personalized recovery plan.
Please list any hobbies and special interests you have *
What would you say your best characteristics are? *
Please list anything else you feel is relevant to this application: *
Do you have anybody you would like to add to your recovery team if accepted into the program. *
Please read  the following statements and initial to indicate your understanding and agreement:
The Phoenix Recovery Home program requires a 1 year commitment. *
The Phoenix Recovery Home program requires a $250.00 non refundable administrative entry fee.   *
Program Fee is $100.00 weekly for individuals and $120 weekly for women and children. Each week begins on Monday and ends on Sunday. *
I agree to take random drug screens for drug and alcohol use that will be administered by management upon request. *
I realize that the Phoenix Recovery Home program for which I am applying for residency requires complete abstinence from  Drugs and/or Alcohol. Any use of Drugs and/or Alcohol is strictly prohibited and will result in immediate eviction from our  residence(s). Disruptive and/or Discourteous behavior within our residence(s) or community will not be tolerated and can/will  result in eviction from our residence(s). Finally, a client’s inability to maintain employment and pay their program fee in a timely manner can/will result in eviction from our residence(s). *
I have read all the material on this application and answered each question honestly. I have a sincere desire to live sober and achieve comfortable recovery from alcoholism and/or drug addiction without relapse. Any questions I may have  had were answered to my satisfaction.   *
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