Start your Application

Have questions? Contact our Certified Recovery Residence Administrator, Dale Gibson

Email
dale4gibson@gmail.com
Phone
954-554-3454

Name

First Name

Last Name

Date of birth

YYYY

Race

Gender

Ethnicity

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number

(###)

###

####

Marital Status

Emergency Contact Name

Emergency Contact Phone Number

Emergency Contact Relationship

Are you currently employed?

Where?

Are you able or do you have assistance to afford the program fees associated with the Hannah's Heritage?

Do you believe that you need detoxification?

Are you currently in treatment for substance use (Therapy, PHP, IOP)?

Please list all past treatment and/or sober living facilities you’ve attended:

Include when and where.

What is your drug of choice?

Sobriety Date:

YYYY

Do you have a sponsor?

Are you currently or open to working a 12-Step Program?

How do you believe that Hannah's Heritage can assist you in reaching your recovery goals?

Please list any medical issues/conditions, psychiatric or mental health diagnoses:

List any known allergies:

Have you been tested for HIV?

Have you been tested for Hepatitis C?

Do you have any disabilities, if yes what are they?

Are you currently enrolled in a Medication-Assisted Treatment program with a licensed physician (MAT)?

Prescribing Physicians Name and Number:

Please list all Medications:

Do you agree to store your medications according to our medication storage policy and procedure during your stay with us?

Do you agree to take your medication as prescribed?

Do you agree to not disclose your medications to other residents?

Have you traveled out of the country in the last 30 days?

Have you come in contact with anyone with an infectious disease?

Have you had a fever in the last 30 days?

Have you been tested for COVID-19?

Date of last COVID-19 Test:

YYYY

Result of last COVID-19 test:

Please describe any psychiatric incidents in the past. (Overdose, suicide attempts, hospitalizations, history of hallucinations):

Any history of harm to yourself or another?

If yes, please describe the incident and treatment received:

Please list any Current or Past criminal charges:

Are you court-ordered to sober living or on probation?

Are you a registered sex offender?

Are you on community control?

Are you on house arrest?

Today's Date

YYYY