Recovery Resident Application

Name(Required)

First Last

Date of Birth(Required)

Age(Required)

Telephone Number(Required)

Current Address

Street Address Address Line 2 City State ZIP Code

Valid Drivers License:(Required)

Yes

License #

Do you own a vehicle:(Required)

Yes

Insured:

Valid state ID:(Required)

Yes

Social Security Card(Required)

Yes

Birth Certificate:(Required)

Yes

What is your motivation to get clean/sober?(Required)

Have you ever been clean/sober before? Explain?(Required)

Have you ever been in a recovery house? Name? Location? Date? Why did you leave?(Required)

Are you currently employed? Are you able to work?(Required)

Are you able to pay A Light Unto My Path's weekly fees?(Required)

Yes

Are you on any current medications? Please list below(Required)

Have you ever tested positive for HIV/AIDS?(Required)

Yes

Hepatitis?(Required)

Yes

Do you feel you need to be on any medications?(Required)

Drug of Choice (DOC):(Required)

Clean/Sober Date:(Required)

Can you pass a drug test/breathalyzer today?(Required)

Yes

Do you have a sponsor?(Required)

Yes

Do you have children?(Required)

Yes

How Many?

Any pending charges? If so, what are they?(Required)

Ever been convicted of assault charges?(Required)

Criminal Sexual Convictions?(Required)

Are you on parole, probation, home detention, etc.?(Required)

Do you have any no contact orders/restraining orders in place?(Required)

Have you ever planned suicide?(Required)

Yes

Attempted suicide?(Required)

Yes

Are you in a relationship?(Required)

Yes

On a scale of 1-1 o, how serious of a problem do you have?(Required)

Please enter a number from 1 to 10.

Do you consider yourself an addict/alcoholic?(Required)

Yes

On a scale of 1-1 O, how motivated are you to change one thing, to recover, with that one thing, being EVERYTHING? (people, places, and things}(Required)

PRIVACY & PROTECTION OF RESIDENT INFORMATION

“A Light Unto My Path” does not meet the definition of a covered entity or business associate as defined by 45 CFR 160.103 and is not subject to or required to comply with the HIPAA Rules and Guidelines. Our current “A Light Unto My Path”resident private confidential information and data collection practices would be considered Protected Health Information (PHI) under HIPPA, therefore” A Light Unto My Path” follows the NARR 3.0 Standard 6 to “Protect resident information It is best practice that residences be guided by HIPPA laws.”

“A Light Unto My Path” Sober Living Homes best practices include strict policies and protocols to protect confidential resident information and PHI including the multi-layered information storage security and secure resident CRM with identity verification and restricted access. Applicant PHI submitted is secure and will only be shared with the Staff and All resident privacy information, PHI, personal and confidential information, regardless of HIPPA or minimum legal requirements will be protected.

LIMITED USE AND DE-IDENTIFIED PHI CONSENT

Under HIPAA GoForth A Light Unto My Path Protected Health Information (PHI) ceases to be PHI if it is stripped of all\ identifiers that can tie the information to an individual at “ A Light Unto My Path”.

A Light Unto My Path utilizes and releases limited use and de-identified data internally and externally for the purposes of operational improvement, statistics and metric tracking, resident outcomes, demographics, grant writing and fundraising, and the addiction recovery community.

BY SUBMITTING THIS FORM YOU AGREE TO THE PRIVACY & PROTECTION OF RESIDENT INFORMATION AND CONSENT TO THE RELEASE OF LIMITED USE AND DE-IDENTIFIED PHI.

A Light Unto My Path Residency Application

Contact Us

Address

Phone

Email