908 783-9815 - Kevin 732 439-2429 - Shawn PhoenixRecoveryLLC@gmail.com
Full Name* Age* Gender* MaleFemale Phone Number* Email* Name of your Insurance Provider* Social Security Number* Are you currently in treatment? If so, where?* Name of Primary Counselor or Case Manager* Primary Counselor or Case Manager’s email* Primary Counselor or Case Manager’s phone number (and extension)* What is your drug(s) of choice?* When was the last time you used drugs or alcohol?* What is your current Recovery Plan?* Have you been in recovery in the past? If so, what was the longest length of sobriety you have sustained?* Have you ever lived in a Recovery House before? If so, when and where?* List of prescription medication(s)* Do you have any co-occurring disorders, such as behavioral or mental health illnesses? If so, what diagnosis(s) have you been given?* Do you have any communicable diseases? If so, what? (This would not prevent you from being accepted into the program, but we do have to know).* Are you currently on Probation, Parole, Drug Court, or have any charges pending? If so, for what?* Do you have any felonies? If so, what was the offense and when did this occur?* Have you ever been accused of or convicted of any violent crimes? If so, what happened?* Have you ever been convicted of arson?* Have you ever been accused of or convicted of a sex crime or are you on Megan’s Law?* Have you ever had any suicide attempts or struggle with cutting? If so, when was the most recent occurrence?* Do you struggle with any Eating Disorders?* If accepted, do you have the finances or funding needed to move in?* Name of person paying move-in fee (Payee)* Payee Contact Information (Phone number)* Will you be attending outpatient services while living at Phoenix Recovery? (PHP, IOP, OP, etc...) If so, where? * What is the best way to currently contact you? (Through your Case Manager/Primary Counselor OR you directly)* Requested Move-In Date*
Request a Call Back and our team will get in touch with you ASAP.