Application

Name *

First

Last

Date of Birth *//

Email *

Phone *

At what facility are you currently being treated? *

Case Manager/Discharge Planner Name and Phone Number *

What is your discharge date? *

When & where have you been treated for substance abuse in the past? *

Have you ever lived in a recovery residence? *

Yes
No

What is the longest length of sobriety that you have had? *

From what city and state will you be moving? *

Which valid forms of identification do you have? *

Driver’s License (active/inactive)
Social Security Card
Birth Certificate
None

Primary substance of choice

Date of last use *

Secondary substance of choice

Date of last use *

Will you be attending outpatient rehab (IOP)? *

Yes
No

If so, at which facility will you be attending?

How many times have you attended inpatient rehab? *

How many times have you attended outpatient rehab? *

Are you seeking residence at Threshold Recovery on your own volition, or is this residency recommendation being forced upon you? *

Have you worked a 12-step program in the past? *

Yes
No

If so, upon which step did you relapse?

Do you have any pre-existing mental, emotional, and/or physical conditions *

Yes
No

If yes please explain:

List all medications you are currently taking: *

Do you have a vehicle? *

Yes
No

Is it in legal operational standards? (insurance, current registration)

Yes
No

Do you have any pending charges, court dates, or outstanding warrants? *

Yes
No

If so, please explain:

Do you have any children? *

Yes
No

If so, how many and their ages:

Will you need to apply for food stamps or renew any forms of identification? *

Yes
No

If so, please explain:

What is your motivation for seeking recovery residency? *

What is your expected length of stay at Threshold Recovery? *

Who will be covering the costs of your lease at Threshold Recovery, you or someone else? *

I will be responsible
Someone else will be responsible

Payor contact name

Payor contact number

My signature below confirms my understanding and agreement to the following terms:

I must be fully detoxed and able to pass a drug screen & breathalyzer upon my arrival to Threshold Recovery.
I agree to abstain from mood-altering substances, which can result in injury, coma, or death during my residency.
I agree to weekly random drug and alcohol screens.
I understand that any violation, on my behalf of Threshold Recovery’s zero-tolerance policy for drug and alcohol use, will result in my immediate dismissal.
I also understand and agree to pay the financial requirements upon my arrival and throughout my residency at Threshold Recovery.

My signature below verifies that this application was accurately completed and by: *

Signature *

Single Line Text

New Resident Application Form