Application

First Name:

Middle Name:

Last Name:

Social Security Number:

Phone Number:

Gender:

Veteran:

Birth Date:

Race:

Emergency Contact Name:

Relationship:

Phone Number:

Current Address:

Are you currently struggling with a mental health or substance abuse issue?:

If YES, please explain (Give a brief description of your current challenges):

Are you looking for help to recover from these challenges?:

What substances have you used in the past year?:

Please list your top 3 substances of choice, beginning with the one you most frequently use::

Have you ever attempted recovery before now?:

If YES, briefly describe your journey:

Have you ever received a mental health diagnosis?:

If YES, please list them::

What medications do you take?:

Please list any Physicians who are treating you for these challenges::

Have you obtained a HS diploma or equivalent?:

If NO, what is the highest grade level that you have completed?:

Have you obtained a degree from an accredited university or trade school?:

Are you currently Employed?:

If YES, where are you working?:

What shift?:

What is the longest job that you have ever held?:

How long?:

How many jobs have you held in the past 12 months?:

Are you capable of holding a steady job?:

Have you ever been fired from a job?:

If YES, for what?:

Do you currently have ANY forms of identification?:

If so, please select all forms you currently have:

Do you have a valid drivers license?:

If NO, are you currently suspended?:

Please explain:

Do you know what is needed to get your driving privileges reinstated?:

If YES, please explain::

Do you have any current/pending criminal cases?:

If YES, please explain::

Have you ever been convicted of a felony?:

Are you currently under criminal supervision?:

Please select the court program you report to:

Please provide your probation officer's name and the county you report to:

Do you have any Sexual or Violent Offenses?:

Are you on the State Registry for ANY offense?:

If YES, please list them below::

May we contact your probation officer?:

Are you currently disabled?:

Receiving Disability Benefits?:

Do you currently have any medical conditions which you are being treated for?:

If YES, please list them::

Do you have HIV, Hep C, or any other bloodborne pathogens that we need to be aware of?:

If YES, please list them::

Are you currently receiving MAT (Medically Assisted Treatment) for a substance use disorder?:

If yes, please list the medications you take::

Who are you receiving your MATs treatment from? (Organization, Physician):

Do you have active medical insurance?:

If YES, who is your provider?:

Do you receive food stamps?:

Do you receive TANF benefits?:

Do you owe child support?:

Amount?:

Do you owe court fees?:

Amount?:

Do you receive disability benefits?:

Amount?:

Have you ever used Recovery Works in the past?:

Are you willing to follow the guidelines for the Rise Residential Program?:

Are you ready to take steps towards your recovery?:

Can you be respectful to staff and other house residents?:

What is your desired move-in date?:

Are you willing to obtain a sponsor or mentor within the next 30 days?:

What specific recovery goals will you have while in our program?:

How long are you expecting to live at our residence?:

Is there anything specific that we might be able to help you with while you stay with us?:

Follow Up:

Once you have completed your application, please call (260) 999-3005 every couple of days and leave us a message. Once we have an opening, we will begin reaching out to applicants who have been checking in regularly.

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Rise Recovery

Application