Name
Email
Phone Number
Birthday
Sex MF
Education Level ---Some High SchoolHigh School Graduate/GEDSome CollegeAssociate's DegreeBachelor's DegreeMaster's DegreeDoctorate/PhD/JD
Do you use tobacco? YesNo
If so, how much? ---Occasional Use1/2 Pack per Day1 Pack per Day2 Packs per Day>2 Packs per Day
Address
State ---ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY
Zipcode
Emergency Contact
Emergency Contact Telephone
Referred by:
Do you currently receive any other funding? YesNo
If so, what benefits do you receive?
Have you ever received any funding from RAF? YesNo
If so, when?
What is your drug of choice?
What non-prescribed drugs have you used in the past year? (check all that apply) OpiatesHeroinCocaineAlcoholCannabisXanaxPCPAcidEcstacyAmphetamineMethMethadoneSuboxoneNoneOther
If "Other", please list
How many times have you been in treatment?
List where and when
How many times have you completed treatment?
Have you ever AMA? YesNo
If so, list where and when
Are you currently in outpatient treatment now? YesNo
If so, where
Have you done IOP before? YesNo
If so, when and where
Did you complete IOP? YesNo
Are you interested in IOP? YesNo
Clean date of all drugs and alcohol since:
Have you been to a 12 step meeting? (check all that apply) NAAACDAHACACR
Have you ever lived in a recovery house? YesNo
If so, where?
Would you be interested in living in a recovery house? YesNo
If so, where would you prefer?
Do you have any medical conditions or special needs? YesNo
If so, what?
Do you have any mental health issues? YesNo
Have you had a psychological evaluation? YesNo
If so, what was the diagnosis?
Do you currently take any medication? YesNo
Do you have a prescription for:
Suboxone:YesNo
Methadone:YesNo
Vivitrol:YesNo
Are you currently employed? YesNo
If so, please list your employer and position?
What is your weekly income?
If not employed, are you willing to fill out seven (7) job applications per week until you find employment as a condition of receiving benefits? YesNo
Do you have any charges pending? YesNo
If so, what are they?
Are you on Probation/Parole? YesNo
If so, when does your probation/parole end?
Explain why this opportunity would change your life