Heart Rock recovery center could be the new beginning you seek

You’ve explored our programming, you’ve visited the premises via our virtual tour and you’ve confirmed you qualify for the long-term sober living program at Heart Rock recovery center. The only thing left to do, is apply.

Apply Online

Fill out our secure, confidential online form below.

Form needs to be completed in its entirety.

Name *

First

Middle

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Previous Address *

Address Line 1

Address Line 2

City

State

Zip Code

Layout

Social Security # *

Date of Birth *

Layout

Phone *

Layout

Gender *

Pronouns *

she/her/hers
they/them/theirs
other

Other *

Layout

Ethnic Background *

Black
Caucasian
Hispanic
Other

Other *

Layout

Valid drivers license *

Vehicle *

Marital status *

Divorced
Married
Separated
Single
Widowed

Layout

Family size *

Number of children *

Layout

Ages/Gender *

Children(s) placement *

Are you pregnant? *

Layout

Do you have an open DCS case? *

DCS FCM Name & Email *

Layout

Military Service *

Branch *

Discharge status *

Highest level of education *

Some high school
High school graduate
Some college
Associate
College graduate
Graduate school
Trade/vocational graduate

Layout

Were you referred? *

Referral name/organization *

Emergency contact

Layout

Name *

Relationship *

Phone *

Layout

Name *

Relationship *

Phone *

Substance Use Information

Layout

Sobriety date *

Length of longest sobriety *

Drug of use *

Alcohol
Benzodiazepine
Crack/Cocaine
Ecstasy
Heroin
K2
Marijuana
Methamphetamine
Other Stimulants
Spice

Other drugs used *

Layout

Frequency of use? *

How do you use? *

Layout

Have you ever used or shared a needle? *

Age of first use? *

Substance Abuse/Mental Health Treatment

Layout

Have you ever been diagnosed with a mental health disorder? *

What was the diagnosis? *

Were you actively using at time of diagnosis? *

Layout

Have you ever had issues with an eating disorder? *

What type of disorder? *

When is the last time you engaged in eating disorder behaviors? *

Are you in a facility? *

Layout

What is the name of the facility? *

Who is your case manager? *

Treatment history

Date

Program Name & Type

Length

Outcome of Treatment

Date 2

Program Name & Type 2

Length 2

Outcome of Treatment 2

Date 3

Program Name & Type 3

Length 3

Outcome of Treatment 3

Date 4

Program Name & Type 4

Length 4

Outcome of Treatment 4

Medical Information

Layout

Do you have medical insurance? *

Insurance provider *

Layout

Insured Name *

Insured DOB *

Layout

Group # *

Insurance # *

Layout

Have you received the COVID-19 vaccine? *

Have you received the COVID-19 booster? *

Layout

Have you tested positive for COVID-19? *

When? *

Layout

Date of your last physical examination *

Physician's Name/Clinic *

Layout

Are you currently under a physician's care? *

For what condition? *

Do you have any medical/physical issues that need to be addressed? *

What are they? *

HIV/HEP/TB/STD's *

HIV
HEP
TB
STD's
None of the above

Layout

Date (HIV) *

(+,-) (HIV) *

Layout

Date (HEP) *

(+,-) (HEP) *

Layout

Date (TB) *

(+,-) (TB) *

Layout

Date (STD's) *

(+,-) (STD's) *

List all medications, include over the counter and prescription.

Name of medication *

Dosage/frequency *

Route *

Reason for medication *

Name of medication 1 *

Dosage/frequency 1 *

Route 1 *

Reason for medication 1 *

Name of medication 2 *

Dosage/frequency 2 *

Route 2 *

Reason for medication 2 *

Name of medication 3 *

Dosage/frequency 3 *

Route 3 *

Reason for medication 3 *

Name of medication 4 *

Dosage/frequency 4 *

Route 4 *

Reason for medication 4 *

Name of medication 5 *

Dosage/frequency 5 *

Route 5 *

Reason for medication 5 *

Name of medication 6 *

Dosage/frequency 6 *

Route 6 *

Reason for medication 6 *

Name of medication 7 *

Dosage/frequency 7 *

Route 7 *

Reason for medication 7 *

Have you been diagnosed with a mental health disorder? *

Please list: *

Layout

Are you currently seeing a therapist? *

Therapist's name/contact *

Have you ever had issues with an eating disorder? *

Layout

What type of disorder? *

When is the last time you engaged in eating disorder behaviors? *

Do you currently have suicidal thoughts or feelings?

Have you thought about how, when or where this would occur? *

Domestic Violence

Have you ever been in a domestic violence situation? *

Are you currently fleeing a domestic violence situation? *

Current partner name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Layout

Phone # *

Length of relationship *

Protective order? *

Criminal History

Do you have any past criminal charges? *

Date *

Charge *

Resolution *

Date 1 *

Charge 1 *

Resolution 1 *

Date 2 *

Charge 2 *

Resolution 2 *

Date 3 *

Charge 3 *

Resolution 3 *

Date 4 *

Charge 4 *

Resolution 4 *

Are you a registered sex offender? *

Layout

Do you have any current charges? *

Pending Charges *

Please list *

Currently on Parole or Probation? *

Layout

County of Parole or Probation *

Probation Officer Name *

Income/Employment History

Layout

Currently employed? *

Place of employment *

Hourly rate *

Layout

Collecting unemployment? *

Collecting disability? *

Layout

SNAP benefits *

TANF benefits *

Most recent work experience

Layout

From & To *

Company *

Position *

Why did you leave? *

Apply Online

Fill out our secure, confidential online form by clicking the button below.

Fill Out Online Form

Apply Via Email

Fill out the PDF form linked below and email it to contact@heartrockrecovery.org

Download PDF

Fill Out PDF

Form needs to be completed in its entirety.

Name

First

Middle

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

County last resided

Address

Address Line 1

City

State

Social Security #

Age

Date of Birth

Phone

Gender

Pronouns

she/her/hers
they/them/theirs

Other

Ethnic Background

Black
Caucasian
Hispanic
Other

Other

Valid drivers license

Drivers license number

Vehicle

Marital status

Divorced
Married
Separated
Single
Widowed

Family size

Number of children

Ages/Gender

Children(s) placement

Do you have an open DCS case?

If yes, DCS FCM Name & Email

Military Service

Branch

Discharge status

Highest level of education

Some high school
High school graduate
Some college
Associate
College graduate
Graduate school
Trade/vocational graduate

Emergency contact

Name

Relationship

Phone

Name

Relationship

Phone

Substance Use Information

Sobriety date

Length of longest sobriety

Date

Drug of use

Alcohol
Benzodiazepine
Crack/Cocaine
Ecstasy
Heroin
K2
Marijuana
Methamphetamine
Other Stimulants
Spice

Other drugs used

Frequency of use?

How do you use?

Have you ever used or shared a needle?

Age of first use?

Were you referred?

Referral name/organization

Medical Information

Do you have medical insurance?

If yes: Insurance provider

Insured Name

Insured DOB

Group#

Insurance#

Have you received the COVID-19 vaccine?

Have you received the COVID-19 booster?

Have you tested positive for COVID-19?

If yes, when?

Date of your last physical examination

Physician's Name/Clinic

Are you currently under a physician's care?

If yes, for what condition?

Do you have any medical/physical issues that need to be addressed?

If yes, what are they?

HIV

Date

(+,-)

HEP

Date

(+,-)

TB

Date

(+,-)

STD's

Date

(+,-)

List all medications, include over the counter and prescription.

Name of medication

Dosage/frequency

3mg/day

Route

Inhaler, injection, oral

Reason for medication

Name of medication (copy)

Dosage/frequency (copy)

3mg/day

Route (copy)

Inhaler, injection, oral

Reason for medication (copy)

Name of medication (copy)

Dosage/frequency (copy)

3mg/day

Route (copy)

Inhaler, injection, oral

Reason for medication (copy)

Name of medication (copy)

Dosage/frequency (copy)

3mg/day

Route (copy)

Inhaler, injection, oral

Reason for medication (copy)

Name of medication (copy)

Dosage/frequency (copy)

3mg/day

Route (copy)

Inhaler, injection, oral

Reason for medication (copy)

Name of medication (copy)

Dosage/frequency (copy)

3mg/day

Route (copy)

Inhaler, injection, oral

Reason for medication (copy)

Name of medication (copy)

Dosage/frequency (copy)

3mg/day

Route (copy)

Inhaler, injection, oral

Reason for medication (copy)

Name of medication (copy)

Dosage/frequency (copy)

3mg/day

Route (copy)

Inhaler, injection, oral

Reason for medication (copy)

Have you been diagnosed with a mental health disorder?

If yes, please list

Are you currently seeing a therapist?

If yes, therapist's name/contact

Have you ever had issues with an eating disorder?

If yes, what type of disorder?

When is the last time you engaged in eating disorder behaviors?

Do you currently have suicidal thoughts or feelings?

If yes, have you thought about how, when or where this would occur?

Domestic Violence

Have you ever been in a domestic violence situation?

Are you currently fleeing a domestic violence situation?

If yes, current partner, Name

Address

Phone#

Length of relationship

Substance use?

Protective order?

Legal History

Criminal History

Date

Charge

Resolution

Date (copy)

Charge (copy)

Resolution (copy)

Date (copy) (copy)

Charge (copy) (copy)

Resolution (copy) (copy)

Date (copy) (copy)

Charge (copy) (copy)

Resolution (copy) (copy)

Date (copy) (copy)

Charge (copy) (copy)

Resolution (copy) (copy)

Do you have any current charges?

Pending Charges

Please list

Currently on Parole or Probation?

County of Parole or Probation

Probation Officer Name

Have you ever prostituted?

If yes, when?

Did you work for someone else while prostituting?

If yes, what was the first name of that person?

If currently incarcerated, do you have a projected release date from jail/prison?

Date

Income/Employment History

Currently employed?

Place of employment

Hourly rate

Collecting unemployment?

Collecting disability?

SNAP benefits

TANF benefits

Work experience: Most recent first, going back 3 years

From & To

Company

Position

Why did you leave?

From & To

Company

Position

Why did you leave?

From & To (copy)

Company (copy)

Position (copy)

Why did you leave? (copy)

From & To (copy)

Company (copy)

Position (copy)

Why did you leave? (copy)

Heart Rock recovery center could be the new beginning you seek

Apply Online

Form needs to be completed in its entirety.

Emergency contact

Substance Use Information

Substance Abuse/Mental Health Treatment

Medical Information

List all medications, include over the counter and prescription.

Domestic Violence

Criminal History

Income/Employment History

Most recent work experience

Apply Online

Apply Via Email

Form needs to be completed in its entirety.

Emergency contact

Substance Use Information

Medical Information

HIV

HEP

TB

STD's

List all medications, include over the counter and prescription.

Domestic Violence

Legal History

Criminal History

Income/Employment History

Work experience: Most recent first, going back 3 years

Recovery
with heart

Share this page

Heart Rock recovery center could be the new beginning you seek

Apply Online

Form needs to be completed in its entirety.

Emergency contact

Substance Use Information

Substance Abuse/Mental Health Treatment

Medical Information

List all medications, include over the counter and prescription.

Domestic Violence

Criminal History

Income/Employment History

Most recent work experience

Apply Online

Apply Via Email

Form needs to be completed in its entirety.

Emergency contact

Substance Use Information

Medical Information

HIV

HEP

TB

STD's

List all medications, include over the counter and prescription.

Domestic Violence

Legal History

Criminal History

Income/Employment History

Work experience: Most recent first, going back 3 years

Recovery with heart

Share this page

Recovery
with heart