Application | ONE12 RECOVERY

Client first name *

Client middle name

Client last name *

Client email *

Client phone *

Client Address *

Client City *

Client State *

Client Zip *

Referring person/facility name and phone number

Client birthdate *

Client race *

Client gender *

Client marital status *

Do you have children; If so what is their ages?

What state were you born in? *

Which documents do you have in your possession? *

State ID
Birth Certificate
Social Security Card

Emergency Contact Info (please give us a few) *

Do you have any CLINICAL Diagnosis? *

Do you have any health problems? Please list all. *

Do you have any allergies? *

What medications are you currently prescribed? *

Treatment center/Halfway house history? Please list all. *

What has your recovery journey looked like up till this point? *

What is your substance or drugs of choice? (Please list all starting with you first choice) *

Do you currently attend meetings? And are you willing to go to 12-Step meetings? *

Do you have a sponsor? *

History of sober living houses or halfway housing? *

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

Do you currently have a job? Tell us about your work history in the past 1 year. *

Where are you currently living? *

What is your motive for seeking recovery residency? *

What is your expected length of stay with One12 Recovery? *

Who will be covering the cost of your stay at One12 Recovery? *

Self
Another person/family member
Agency

Person or agency's contact information. (Put self if you will be paying) *

Client contact number *

Printed Name *

Signature *

The ONE12 RECOVERY Journey

At ONE12 RECOVERY, we utilize a level-based approach to guide women through their recovery journey, fostering growth and independence every step of the way.

Location

Chattanooga, TN