Recovering Hands Resident Application

Please complete the form below and follow the additional steps to complete your application.

Read over the Residents Agreements.
Submit your Primary Financial Application if you aren’t paying for yourself.
Have your Guarantor fill out the Secondary Financial Application.
Fill out the Craig Buley Memorial Scholarship Application if requesting a scholarship and ask two people to email letters of reference to kim@recoveringhands.com.
Check out the Slideshow Presentation to get a feel for what Recovering Hands looks and feels like.

Please complete all required steps to avoid delays in processing your application.

Today’s Date

This field is required.

Your First Name

This field is required.

Your Last Name

This field is required.

Your Email Address

This field is required.

Desired Date to be accepted into Recovering Hands Program

This field is required.

Social Security Number

This field is required.

Date of Birth

This field is required.

Phone Number

This field is required.

What is your monthly gross income?

This field is required.

What is your Address?

Address Line 1

This field is required.

Address Line 2

This field is required.

City

This field is required.

State

This field is required.

Postal Code

This field is required.

Country

What is your marital status?

This field is required.

What is your level of education completed?

This field is required.

Are you Pregnant?

This field is required.

Do you have a Valid Driver’s License

This field is required.

Do you have a car? If yes, is it registered and insured?

This field is required.

Current Treatment Center and Expected Discharge Date

This field is required.

Who referred you to us?

This field is required.

Recovery and Substance Use

Primary Addiction

This field is required.

Date of Last Use

This field is required.

List drugs/alcohol you’ve used addictively along with how you’ve used them (route), Date of last use and age of first use.

This field is required.

Emergency Contact

Full Name

This field is required.

Relation to you

This field is required.

Phone

This field is required.

Address

This field is required.

Other Information

What would you say your best characteristics are

This field is required.

Please list hobbies and special interests

This field is required.

Employment

Are you currently employed? If yes, Name and phone number

This field is required.

Address of current employer

This field is required.

List your last 3 employers with company name, supervisor and contact information

This field is required.

Please list your vocational skills/specialized training or certifications

This field is required.

Legal

Have you been arrested in the last 30 days?

This field is required.

Are you currently on probation or parole? if yes, please provide your probation officer’s name and phone number (you will be asked to complete a Release of Information form when you arrive)

This field is required.

Why are you on probation (be specific)

This field is required.

Are you court mandated to attend a treatment program?

This field is required.

List dates of upcoming court appearances and explain if you checked other

This field is required.

Detail any obligations to contact your Probation Officer, Lawyer, Judge or any other legal entity over the next 90 days. Failure to list these things may result in not being able to meet these obligations while continuing your program at Recovering Hands

This field is required.

Medical

Do you have a medical Doctor? If yes, Name and phone number (You will be asked to fill out a Release of Information form when you arrive)

This field is required.

Medical Doctor’s Phone Number

This field is required.

What is your height?

This field is required.

What is your weight?

This field is required.

Do you have any special dietary needs? If yes, please describe

This field is required.

Please list all medications with their names, dosages and how many times per day you take them. (Also list non-prescription medications you take on a regular basis)

This field is required.

Are you able to obtain a 90-day supply of your medications: (We use CVS. You may need to switch your prescriptions over to this pharmacy)

This field is required.

Do you have any medical conditions or allergies? If yes, please explain. (Be sure to list if you feel you will need to make any doctor appointments during your program at Recovering Hands. Failure to do so here may result in you not being able to do so.)

This field is required.

Recovery History

Have you ever attended a 12-step meeting?

This field is required.

Do you already have a sponsor, a Peer Recovery Specialist or a Recovery Coach? If yes, please provide name and phone number and you may be asked to fill out a Release of Information form when you arrive.

This field is required.

Phone Number of sponsor, PRS or Recovery Coach

This field is required.

Do you have any other recognized addictions or disorders (i.e. Eating disorder, cutting)? If yes, please explain:

This field is required.

How long have you been Clean/Sober:

This field is required.

What is the longest you have gone substance free:

This field is required.

Describe previous recovery attempts/relapses if you have had them:

This field is required.

Are you on any drug maintenance programs?

This field is required.

If yes, tell us about it. Be sure to list the medication and dosage:

This field is required.

If you are currently on a maintenance program, please describe your plan and goals for this program:

This field is required.

Please state if you intend to continue this program throughout your stay here or if you are interested in getting help tapering off your medication assisted treatment.

This field is required.

Please give us your MAT doctor’s name and phone number. You will be asked to fill out a Release of Information form when you arrive:

This field is required.

Other Information

Have you ever lived in a home with other people who were not your family? If yes, please explain?

This field is required.

Do you anticipate any problems with this? If yes, please explain:

This field is required.

We support healthy eating. Our goal is to provide an atmosphere where you can become accustomed to what it feels like to nourish you mind, body and spirit. We order our groceries electronically and do not provide soda or sweets. RH staff is not obligated to go into the stores to purchase cigarettes or any other items. If a staff member agrees to do this, please know they are doing you a favor. If you smoke, you are allowed to bring your cigarettes can also have them mailed to you. If you decide you wish to quit smoking, we will support you in this decision. There is absolutely no smoking anywhere on the property except where there is an ashtray. Do you understand and agree:

This field is required.

What is your main goal at this time:

This field is required.

Please tell us why you are would like to come to Recovering Hands. If you also are asking for a scholarship, please know that your answer to this question will help us to determine your eligibility for financial aid consideration.

This field is required.

Data Privacy and Consent

I agree to the terms of service. Please write your name below.

This field is required.

Checkbox

This field is required.

Please tell us why you would like to come to Recovering Hands. If you are also asking for a scholarship, please know that your response to this question will help us to determine your eligibility for financial aid consideration. Is there any other Information that you can provide to help us decide if we can help you.

This field is required.

After submitting this application be sure you

read over the file containing the Residents Agreements (https://recoveringhands.com/residents-agreements)
Submit your Primary Financial Application and if you aren’t paying for yourself. (https://recoveringhands.com/primary-guarantor-financial-application)
Have your Guarantor fill out the Secondary Financial Application. (https://recoveringhands.com/secondary-guarantor-financial-form)
Fill out the Craig Buley Memorial Scholarship Application if you would like to request a scholarship and request two people to email a letter of reference to kim@recoveringhands.com

Please check out the Slideshow Presentation, too. It will help you to get a feel for what Recovering Hands looks and feels like. (https://recoveringhands.com/presentation)