Child(ren) (if applicable) with age (see women & children section):

1. Have you ever been a client of Foundation to Freedom?

YES NO

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?

Last day that you used:

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 with any mental health disorder?

22. Are you currently on any medications?

23. 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:

21. Fees:

a. Intake Fee (all) - $60.00, b. Weekly Fee (single male/female) - $180.00, c. Weekly Fee (woman with child(ren) - $200.00

22. Do you have any questions for Foundations?

The correctness of the information

23. 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.

Client Assessment for Admission