Rise Recovery

Application

First Name *

Last Name *

Email *

Phone *

How Did You Find Out About Us? *

(If Refered) Who Referred You to the Program?

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

Personal Information

Date of birth *

Address *

City *

State *

Zip code *

Additional Contact Info

What are your life controlling issue(s)? *

Are you legally married? *

Name of spouse.

Are You Currently on Probation or Parole? *

Who is your Probation or Parole Officer?

Mental Health Questions

Have you ever been diagnosed with any psychiatric or mental disorders? *

If so, what was the diagnosis and when?

Describe your mental health. *

Medical Information

Are you currently taking medication prescribed by a doctor? *

If yes, please list medications, diagnosis, and how long you have been taking each medication?

If you are accepted into our program, how will you pay for your medications? *

Do you have dental issues? *

If so, please explain

Insurance Questions

Do you have health insurance? *

If yes, what is the name of your carrier?

What is your Social Security Number? *

Physical Question

Do you have any physical disabilities that would prevent you from daily exercise or physical work? *

If yes, please describe.

Can you walk 2 miles a day? *

If no, please explain.

Which Drug? *

Additional Questions

How do you believe Rise Recovery can help you and what are you willing to do? *

What is your spiritual background and/or view of God? *

Are you homeless at this time? *

Are you pregnant or do you have children? If you have children, who has custody? *

Signature *