Intake Application

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Intake Application

Our purpose for the initial assessment is to gather basic information about you and the problems and pain that addiction has caused you and your loved ones. So we require that this form, ONLY be filled out by the person being assessed. if that is not an option at this moment, please contact us directly and we will be glad to help you.

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Full Name

First

Last

Gender

Male
Female

Emergency Contact

In case of an Emergency please contact... Name / Phone # / Relationship

List of Authorized People - By entering a person(s) name below, you herby AUTHORIZE the exchange of information between S2L Recovery and the person(s) listed below. If you do not wish to authorize anyone, please type "NONE" Enter: Full Name / City andState of Residence / Phone Number (with area code)

Do you have any upcoming court dates within the next 30-90 days? Do you have any upcoming court dates within the next 30-90 days?

If you answered yes above, please list the date(s), location and charges below.

Are you currently supervised on any type of federal, State or County Probation, Parole or Supervision?

No
Yes - (Please explain below)
Not Yet

If you answered "YES" or "NOT YET" to the question above, please explain below.

Are you ordered, mandated, sentenced furloughed or required to attend and/or complete a program by a court or supervision office?

No
Yes - (Please explain below)

If you answered "YES" above, please explain the details of the court order or stipulations including length of stay, the state, city and county the order came from as well as the judge(s) and/or probation/parole officer(s) name(s) on the order and their contact info.

Have you ever been convicted of a violent felony?

No
Yes - (Please explain below)

If YES, please list the name(s), type(s), year(s) and result(s) of the conviction(s). For example, if you had a felony theft, you would type: Theft, felony, 1995, 3 years probation. If you have never been convicted of a violent felony, just type NONE.

Have you ever been convicted of a sexual crime?

No
Yes - (Please give brief explanation below)

Please check a box (below) that represents your answer to the paragraph (above).

I Agree
I don't agree

Are you allergic to any medications, foods, plants or material?

No
Yes - (Please explain below)

Probation, following problems

Comment(s) about the question above

Have you had any injuries or diagnosed with any conditions (physical or mental) that required or resulted in you being hospitalized or treated by a medical professional within the past 6 months?

Yes - (Please explain below)
None
Other

If you answered "YES" OR "Other" to the question above, please explain.

Do you have ANY physical or mental conditions which require ongoing medical treatment by a medical professional.

Yes - (Please explain below)
None

If you answered "YES" to the question above, please explain.

Are you currently prescribed any narcotic medication(s) classified as a "controlled substance"?

Yes - (Please explain below)
None
Im not sure. (If not sure, please express your concerns below)

If you answered "yes" above, please explain the medication you are taking and how long you have been taking it in the following format: MEDICATION NAME / STRENGTH / DOSAGE INSTRUCTIONS / REASON IT IS PRESCRIBED. If you answered "Im not sure" please list the medication as instructed OR simply type your concerns or question.

Are there any other medical or mental health related conditions, problems or upcoming appointments that have not already been addressed on this assessment, we need to know about?

Please respond by typing "NONE" if there are no other conditions, or explain (below) any medically related issues that have not already been addressed on this assessment.

Supervised "Self Administered Medication"

I Agree
I Do not agree

Service Recipients (SR's) at S2L Recovery who take prescribed medication must "Self Administer" their medications under the supervision of the program staff. S2L Recovery provides locked boxes for SR's to store their medication and may self administer their medications at scheduled times. All medications must be taken ONLY as directed by the prescribing physician(s), ANY suspected misuse or misconducted must immediately be reported to the prescribing physician or proper authorities. By checking the "I agree" box below, you are declaring that you understand our policy for medications and here by wish to release and forever hold harmless, S2L Recovery and any and all contractors or affiliates from any liabilities, damages, suites or claims resulting from or in relations to my prescribed medications. If not, please check the "I do not agree" box.

What is your drug of choice?

List the MAIN (one or two) chemical, addictions or behaviors that have caused the most problems for you recently.

When was the last time you used?

List your most recent usage or consumption of ANY drug(s) or alcohol (including your drug of choice) Please respond in the following format: "DRUG NAME / AMOUNT USED/ LAST DATE and TIME USED"

Do you currently have, or expect to have, any physical withdrawal symptom(s)?

No
Yes (If Yes Please Explain Below)
Im not sure. ( If not sure, please express your concerns below)
Other (explain below):

Comment(s)

Have you used any of the following 3 drugs/chemicals on a daily or regular basis within the past 6 months...

BENZODIAZEPINES: Xanax / Valium / Klonopin / etc.
ALCOHOL: Beer / Whisky / Wine / Cocktails / Mixed Drinks / etc.
OPIATES or OPIOIDS: Herion / Morphine / Hydrocodone / Oxycodone / Methadone / etc.
NONE OF THESE
OTHER

Answer by checking the boxes above. If you check one or more of ANY of the boxes, please provide a brief description of the frequency your usage, the amount of usage and the length of time you have used.

If you checked ANY of the boxes above (except "NONE OF THESE") please comment below in the following format: "Valium / twice daily /10mg / for 6 months"

If you answered "Other" to the question above, please feel free to explain.

What faiths, beliefs or denominations (if any) have you observed, practiced, participated, studied or followed in the past?

Recovery Plan Packages:

(42 DAY) COURSE - PERSONAL RECOVERY PLAN -- $24,400.00
(84 DAY) COURSE - PERSONAL RECOVERY PLAN -- $36,900.00
I PLAN TO USE MY INSURANCE
MEDICAL DETOX (Length of stay determined by attending physician / Typically 4-7 days) -- $5,600.00
Other:

Please select a Recovery Plan and Payment option that is best suited to your needs at this time. Please select the Recovery Plan that represents your desired length of stay.

If you answered "Other" to the question above, please feel free to explain.

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