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Client Assessment for Admission
Screening Date:
Full Legal Name:
DOB:
Contact Information:
Email
Referring Agency or Self-Referral:
Date of Release:
Child(ren) (if applicable) with age (see women & children section):
1. Have you ever been a client of Foundation to Freedom?
YES
NO
1a. If so, when?
1b. Why did you discharge?
2. Where are you currently residing?
3. What is the reason for seeking recovery housing?
4. Do you have a substance use concern with either alcohol and/or other drugs? If so, are you willing to work towards sustained recovery?
YES
NO
What is your substance use history?
How long?
Last day that you used:
What substances:
5. Are you able to pass a drug test and breathalyzer?
YES
NO
6. Are you in need of detox?
YES
NO
7. Do you consent to random/supervised drug and alcohol testing during your stay?
YES
NO
8. Can you provide a copy of a government-issued ID verifying your name and age?
YES
NO
9. If accepted as a Foundations client, do you understand if you use a substance while a client, you may face expulsion from Foundations?
YES
NO
10. Are you willing to provide Foundations with an emergency contact?
YES
NO
11. Do you understand that all client personal property, vehicle, and person will be searched upon arrival and at any time during your stay?
YES
NO
12. Are you able to manage basic daily living activities on your own (e.g., bathing, dressing, eating, evacuating the home during emergencies)?
YES
NO
13. Once a Foundations client, do you understand that you may not take any Schedule II medications unless under dire medical emergencies as determined by a licensed physician, approved by Foundations staff, and taken while not residing at Foundations property (i.e. Emergency Room or surgery)?
YES
NO
14. Do you agree to adhere to all Foundations house rules and act in a good manner while a Foundations client (this includes: attending mutual support groups regularly, adhering to the support groups recommendations for recovery, and attending weekly Foundations house meetings)?
YES
NO
15. Are you currently on probation, parole, or a fugitive? Yes No
YES
NO
16. To your knowledge, do you have an open warrant for arrest in any state (A warrant search will be performed on all potential clients)?
YES
NO
17. Are you registered as a sexual offender or predator?
YES
NO
18. Have you been convicted of child abuse or child neglect?
YES
NO
19. Are you currently enrolled in a Medication-Assisted Treatment program with a licensed physician?
YES
NO
19a. If so, what is the MAT protocol are you currently participating?
19b. Does client agree to keep medications confidential and not disclose your medication to other clients?
YES
NO
20. Do you have any physical limitations? (Please list)
21. Have you ever been diagnosed or suspected that you have a mental health condition?
21a. Are you now on or have you ever been prescribed mental health medication?
YES
NO
22. Are you currently employed or in school?
YES
NO
23a. If not, are you able to work?
YES
NO
23b. Responsible for weekly fees?
SELF-PAY
FAMILY
AGENCY
23c. If other than self-pay, who will pay fees?
23ci. Contact information:
24. Fees:
a. Intake Fee (all) - $60.00,
b. Weekly Fee (single male/female) - $180.00,
c. Weekly Fee (woman with child(ren) - $200.00
25. While a client, do you agree to use Customer Relationship Management software on your mobile device, that requires GPS/location information, opt to always leave your location on, and to never disable the software?
YES
NO
26. Do you have any questions for Foundations?
27. Are you currently on any medications?
28. The correctness of the information
Do you attest that all the above information is true, and is correct to the best of your knowledge, and you also understand that any falsified information on this questionnaire is grounds for non-entry and/or your future dismissal from Foundations?
I, hereby being bound and fully aware, acknowledge and agree that all the above information is true, and is correct to the best of my knowledge, and I also understand that any falsified information on this questionnaire is grounds for non-entry and/or my future dismissal from Foundations.
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