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First at Blue Ridge Application

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Application for Admission

FIRST at Blue Ridge, Inc.

32 Knox Road

Ridgecrest, NC 28770

Firstinc.org

Important

For this application to be considered, all sections must be filled out COMPLETELY, including appropriate signatures (personal, witness, and physician signatures).

Personal Information Section

Name *

First

Middle

Last

Age *

Today's Date *

Program Applying for: *

Longterm
Shortterm
Veterans

If Short-term, how many days? *

Current Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number

Do you have a Social Security Number? *

Do you have a copy of your Social Security Card? *

SSN *

Gender *

Male
Female

Are you Pregnant? *

Date of Birth *

Birth City *

Birth State *

County *

Height *

Weight *

Hair Color *

Eye Color *

Distinguishing Marks (tattoos, scars)

Relationship Status *

Married/Co-Habitating
Divorced
Single/Never Married

Spouse or Significant other’s name *

1st Divorce Date *

2nd Divorce Date

3rd Divorce Date

1st Divorce County *

2nd Divorce County

3rd Divorce County

1st Divorce State *

2nd Divorce State

3rd Divorce State

Do you maintain a primary residence? *

Are you homeless? *

How long have you been homeless? *

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Family Information

Do you have Children? *

How Many Children do you have? *

Father *

Living
Deceased

Father's Name *

First

Last

Father's Address *

Address Line 1

Address Line 2

City

State

Zip Code

Mother *

Living
Deceased

Mother's Name *

First

Last

Mother's Address *

Address Line 1

Address Line 2

City

State

Zip Code

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In case of Emergency notify: *

Phone Number of Emergency Contact *

Relationship *

Referred By *

Have you ever Applied to First Inc before? *

Were you accepted? *

Please list the Date(s) & Month(s) completed *

Do you have a current valid Driver’s License? *

What is the driver’s license number and state issued *

Have you ever had a driver's liscense? *

Please list any outstanding tickets, fines, etc. with the county and state where the infractions took place:

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Military Service Information

Have you ever served in the Military? *

Branch of service *

Eligible for benefits? *

Yes
No
Unknown

Service Number

Number of Grant Per-diems previously used *

Type of Discharge *

Year Discharged *

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Criminal Justice Information

Please read carefully and answer truthfully - Failure to answer truthfully will cause you to be exited from the program

Have you ever been convicted of a crime?

Have you ever commited or been charged with:(choose all that apply) *

Child Abuse/Neglect
Arson
Sexual Offense
Assault or Domestic Violence
No

Have you ever been convicted of:(choose all that apply) *

Child Abuse/Neglect
Arson
Sexual Offense
Assault or Domestic Violence
No

Explain Child Abuse/Neglect *

Explain Arson *

Explain Sexual Offense *

Explain Assault or Domestic Voilence *

List All Prior Convictions

Offense *

Offense2

Offense3

Offense4

Offense5

Offense6

Disposition *

Disposition

Date *

Date

Are you currently on Probation or Parole? *

Probation/Parole Officer's Name *

Probation County *

Probation/Parole Officer's Phone

Probation/Parole Fax Number

Probation/Parole Office Address

Address Line 1

Address Line 2

City

State

Zip Code

Do you have any pending legal actions? *

What is your current offense and status? *

Please list pending legal action(s) by name and date *

If the case(s) have not been disposed of, when is your next court date? *

Date

Time

City *

State *

Attorney's Name

First

Last

Attorney's Phone

Attorney's Fax

County *

Judge

Attorney's Address

Address Line 1

Address Line 2

City

State

Zip Code

Do you have any pending warrants? *

Warrant for: *

Warrant for:

City *

City

State *

State

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Employment Information

Have you ever been Employed? *

Are you currently Employed? *

Current Employers Name *

Previous Employer's Name *

Last/Current From Date *

Last/Current to Date *

Reason no longer there? *

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Financial Information

Do you have any outstanding debts? *

Outstanding debts (child support, installment loans, IRS, etc.) *

Arrangements for Payments, Explain? *

Are you ordered to pay Child Support? *

Are you behind on Child Support? *

How far behind are you? *

Do you receive any ongoing financial reimbursement for any reason? (Such as disability ,trust funds ,annuities etc.)? *

Explain reimbursements *

Are you currently applying for disability (SSI, SSDI)?

For what reason are you appling for disability? *

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Substance Abuse Information: (This information is confidential and will not affect your acceptance into the program) List in order of preference all drugs used or tried; past or present (This MUST be complete)

Drug of choice *

Age of first use *

At most daily *

Date of last use? *

2nd Drug of choice

Age of first use

At most daily

Date of last use?

3rd Drug of choice

Age of first use

At most daily

Date of last use?

4th Drug of choice

Age of first use

At most daily

Date of last use?

5th Drug of choice

Age of first use

At most daily

Date of last use?

6th Drug of choice

Age of first use

At most daily

Date of last use?

7th Drug of choice

Age of first use

At most daily

Date of last use?

8th Drug of choice

Age of first use

At most daily

Date of last use?

Prior drug treatment programs and dates completed

Do you have knowledge of 12 step programs? *

Have you ever participated in 12 Step Fellowships? *

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Education Information Section

High School Graduate? *

Any College Classes? *

GED obtained? *

College Degree? *

Last School grade completed *

Degrees earned (choose all that apply) *

AAS
Bachelors
Masters
Doctorate

Do you have any difficulty reading? *

Do you have any difficulty writing? *

Do you have any Vocational or Occupational Education? *

Describe/List Vocational or Occupational Skills *

Describe/List any special areas of study

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Medical Information Section

Are you on Medicaid? *

Do you have Insurance? *

Please list your Insurance information *

Do you have Dental problems? *

Describe your Dental problems? *

Are you currently on any medications? (Prescribed or Over-the-counter) *

Medication 1 *

Medication 5

Medication 9

Medication 13

Medication 17

Medication 2

Medication 6

Medication 10

Medication 14

Medication 18

Medication 3

Medication 7

Medication 11

Medication 15

Medication 19

Medication 4

Medication 8

Medication 12

Medication 16

Medication 20

This party will sign an affirmation that they will pay for the meds.

Who is paying and/or providing for your medications? *

Are you currently under the care of a physician? *

Physician's contact information *

Reason for Physician's Care? *

Have you been tested for Tuberculosis(TB) in the past year? *

Tuberculosis(TB) test result *

Positive
Negative

When is the last time you have had unprotected sex? *

Have you ever been tested for HIV/AIDS, STDs, HEP A,B,C,D,E? (choose all that apply) *

HIV Aids
STD's
Hep A,B,C,D,E
None

Date of HIV/Aids test *

Result of HIV/Aids test *

Date of STD test *

Type of and Result of STD test *

Date of HEP test *

Type of and result of HEP test *

List any Medical Problems?

Have you ever been hospitalized for any illnesses? *

hospital(s) and date(s) *

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Medical continued: Allergies: Are you allergic to:

Do you have any known Allergies? *

What Allergies do you have? *

Penicillin or Sulfa
Asprin, Codeine, Morphine
Mycins or other Antibiotics
Merthiolate, Mecurochrome
Other Drugs?
Nail Polish or Cosmetics
Adhesive Tape
Any Food?
Other Allergies?

List other Drug Allergies *

List Food Allergies *

List Other Allergies *

Do you have a history of: (Check all that apply) *

Asthima
TB
Diabetes
Hepatitus
Heart Disease
Epilepsy
Seizures
None

Seizure caused by and when *

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Medical Continued: Injuries and Surgeries Information

Have you had any of the following injuries? (choose all that apply) *

None
Concussions or Head injuries
Sprains
Dislocations
Lacerations
Broken or Cracked Bones

Concussions/head injuries When? *

Sprains When? *

Dislocations When? *

Lacerations When? *

Broken/cracked bones When? *

SURGERY

SURGERIES: Have you had any of the following surgeries:(Choose all that apply) *

Tonsillectomy
Appendectomy
Other Surgeries
No

Other Surgery Type and Year *

Other Surgery Type and Year

If you have ever been advised to have any surgical operation which has not been done? *

Please provide details *

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Mental Health Information

Have you ever been hospitalized and/or treated for any mental health issues? *

Voluntary or Involuntary? *

Voluntary
Involuntary

Hospital(s) and Date(s) *

Reason/Diagnosis *

Have you ever been given a mental health diagnosis? *

Please list your specific diagnosis(es) *

Have you ever heard voices? *

When did you hear voices? *

What was the Outcome? *

Have you ever had visual hallucinations? *

When did you have visual hallucinations *

What was the Outcome? *

Have you ever beed sexually assaulted? *

Date(s) of sexual assault? *

Have you ever received counseling for the sexual assault(s)? *

Are you currently Suicidal? *

Have you ever tried to commit Suicide? *

List the date(s) of attempt(s) *

Have you ever exhibited any self-harm behaviors such as cutting, bulimia, etc? *

Please explain self-harm behavior(s) *

Have you ever overdosed? *

How many times? *

Circumstances surrounding overdose (when, where, why, how): *

Have you ever been a victim of a violent crime? *

Please explain the violent crime: *

Do you currently have a mental health provider? *

Please list current provider(s): *

Have you recieved counseling in the past? *

Please list past provider(s): *

On the following scales 1) being No problem or Not motivated to 10) Very serious or Very motivated:

On a scale of 1 to 10, how serious is your problem with drugs and alcohol? (Choose one) *

On a scale of 1 to 10, how motivated are you to make positive changes in your life? (Choose one) *

AFFIRMATION

I affirm that my answers and information provided by me in this application are true and accurate. I understand that if I am accepted in the program, any misinformation and/or dishonest answer may be grounds for my dismissal from the FIRST at Blue Ridge Program. I also understand that should any other information concerning me arise while I am in the FIRST at Blue Ridge Program that renders me ineligible to continue, I will be discharged.

Signature *

Clear Signature

Date *

This is a good place to save and take a break, the next section is your autobiography and requires 1000 to 1500 words

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Autobiography

Outline for Applicant’s Autobiography

“We admitted we were powerless over our addiction and that our lives had become unmanageable.”

It would be impossible to overestimate the importance of being thoroughly and completely honest with yourself and others. Each client is required to write an autobiography including a history of their substance use, mental health issues, and goals for treatment and recovery.

Issues to be covered in your autobiography are:

Describe your substance use history, including what and how long you have used it.
Have you ever been in the hospital for mental health reasons? Explain in detail.
Have you ever tried to commit suicide?
Discuss any mental health issues including diagnoses and history.
List what medications you are taking and why.
Describe your present situation – be as specific as possible.
Why do you want to be admitted to FIRST?
Discuss specific changes you want to make in your life.
What goals do you want to achieve while at FIRST?
What are your goals for recovery?
How will you contribute to the program and your fellow residents?

Minimum Length: 1000 words

Your personal autobiography should be at least 1000 to 1500 words in length, and should be typed in chronological order as to how and when the events occurred.

This autobiography is CONFIDENTIAL. At your request, it will be returned to you at time of discharge. This autobiography will help us determine if you are appropriate for our program and how we may best serve you.

Use the word counter provided below the text field to ensure you have used a minimum of 1000 words

Autobiography *

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ACCEPTANCE AND AGREEMENTS

Information for Applicants

No violence, threats of violence or use of drugs/alcohol will be tolerated - you will be discharged and the proper authorities will be notified.
The preppie phase will last 30 days or until initial treatment plan goals have been met, depending on your participation in the program. During the preppie phase, between the hours of 6:30am – 10:00pm, clients will be scheduled for a variety of activities including educational classes, group therapy, 12-step meetings, work assignments, chores, etc.
A 15-minute personal phone call is allowed to an approved number once per day, and any time on the weekends.
Business calls may be made after 9:00am on weekdays for legitimate reasons only.
After the preppie phase, residents can earn a day pass every 30 days.
You may be eligible to go on a 4-day home visit after 6 months, depending on how well you are doing in the program.
If you bring cash, credit cards or debit cards, they will be stored in the administrative office, not kept on the client. No more than $200 will be allowed to be stored at any time.
Do not bring computers, cell phones, TVs, stereos, weapons, pornography, or clothing with alcohol/drug symbols or profanity.
Do not bring any tight-fitting or revealing clothing.
All clients will receive a work assignment after completion of the preppie phase in order to help support the facility. These will be based upon client skills, house needs and other criteria.
You must use the chain of command if you have any questions. If you need anything, ask your Peer Leader or House Manager.
Be humble and do what is asked of you. If you have a problem with something you are asked, do it to the best of your ability, then follow the chain of command to let someone know how you feel about the situation.

By signing below, you are confirming that you have been made aware of these rules during the Application process, and if accepted into the program, agree to abide by them.

Name *

First

Middle

Last

Signature *

Clear Signature

Date *

Items to Bring

Necessary Items:

Court document(s) if probated/court ordered to FIRST at Blue Ridge, Inc.

Identification (State I.D./S.S. Card)

Veterans Identification (if eligible: DD-214 form is required)

(30) day supply of medication(s) and AT LEAST a 90 day refill.

(10) day supply of clothing (work, casual, and formal)

Steel Toe Boots

Suggested Items:

Hygiene materials (alcohol free)

Alarm clock

Electric razor/beard trimmer or disposable razors

AA/NA Books

Bible

Writing paper

Pens/pencils

Hobby/leisure items such as musical instruments and/or art supplies

Hair clippers (for personal use ONLY)

Items NOT to bring:

Weapons (real or fake)

Anything containing alcohol (cologne, mouthwash, etc.)

Pornography

Vapes

Stereos, Televisions, Computers, cellphones/pagers, Bluetooth devices

Drug paraphernalia, clothing with alcohol/drug symbols or profanity

Anything of value (such as jewelry)

FIRST Inc. will not be responsible for items left after a resident leaves the program.

NOTE: Unauthorized items may be confiscated.

I understand that if I bring items other than those specifically listed above, the items will be disposed of at the time of my entry into the program. The list above is all-inclusive; there are no exceptions.

Name *

First

Middle

Last

Signature *

Clear Signature

Date *

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AUTHORIZATIONS TO RELEASE

INFORMATION

CRIMINAL JUSTICE SYSTEM REFFERALS

I,_(Type name below)_authorize the following: *

First

Middle

Last

Name of program which is to exchange information:

FIRST at Blue Ridge, Inc.

32 Knox Road

P.O. Box 40

Ridgecrest, NC 28770

Name or title of the person(s) or organization(s) with which the disclosure is to be made:

Court having jurisdiction over the resident.

Probation and/or parole officers or their agencies

TASC referral units

Prosecuting attorney withholding charges against the resident

Defense attorney

Department of Social Services and/or its agents

Purpose or need for the disclosure:

For assessment and treatment planning, to monitor progress in treatment and compliance with conditions of referral.

Extent or nature of information to be exchanged:

Any and all pertinent information contained in files.

This consent is subject to revocation at any time except to the extent that FIRST, Inc. has already taken action in reliance on it. If not previously revoked, this consent will terminate three hundred sixty-five (365) days after termination of treatment.

Signature *

Clear Signature

Date *

Witness Name *

Witness Signature *

Clear Signature

Date *

General Consent

I,_(Type name below)_authorize the following: *

First

Middle

Last

Name of program which is to exchange information:

FIRST at Blue Ridge, Inc.

32 Knox Road

P.O. Box 40

Ridgecrest, NC 28770

Name or title of the person(s) or organization(s) with which the disclosure is to be made:

Family and significant others of resident; employers and potential employers;

Funding sources; the Department of Social Services; psychiatric, medical, or treatment personnel;

Social Security Administration; Food Stamp offices.

Purpose or need for the disclosure:

In order to provide relevant information as to resident’s treatment status or progress and for follow-up

investigation.

Extent or nature of information to be exchanged:

Only such information as is reasonable and necessary for the particular circumstance.

Signature *

Clear Signature

Date *

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AGREEMENT TO ACCEPT TREATMENT AT

FIRST AT BLUE RIDGE

I,_(Type name below)_acknowledge and agree to each of the following: *

First

Middle

Last

As a client and participant in the long-term treatment program offered at FIRST at Blue Ridge, I am expected to participate in work therapy assignments under the direction of FIRST staff and its community partners. I understand this means that any and all situations where my ability to participate in work therapy as directed is compromised or otherwise affected may conflict with FIRST’s goals for my long-term treatment, and therefore such situations require FIRST’s reconsideration as to my appropriateness for the program.

Initial *

Clear Signature

Date *

Such situations include, but are not limited to: recommendation for Intensive Outpatient Programs, medical diagnosis that affect my ability to participate in work therapy, changes in medication that affect my ability to participate in work therapy, prescriptions for medications that are not allowed in the FIRST program, operations and surgery that affect my ability to participate in work therapy, and recommendations for treatment that conflict with, or are contrary to, FIRST’s recommendations for treatment.

Initial *

Clear Signature

Date *

I understand and agree that FIRST makes every effort to assist with transition planning for its clients, and that my acceptance and pursuit of other treatment recommendations may mean that my transition would best be handled by those making such recommendations. This includes, but is not limited to, other agencies and their personnel, family, friends, doctors, and other medical providers.

Initial *

Clear Signature

Date *

By signing and dating below, I am acknowledging and agreeing to the above and confirming that I desire the treatment provided by FIRST at Blue Ridge.

Signature *

Clear Signature

Date *

Witness Name *

Witness Signature *

Clear Signature

Date *

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First at Blue Ridge Application

Application for Admission

Important

Personal Information Section

Family Information

Military Service Information

Criminal Justice Information

Please read carefully and answer truthfully - Failure to answer truthfully will cause you to be exited from the program

List All Prior Convictions

Employment Information

Financial Information

Substance Abuse Information: (This information is confidential and will not affect your acceptance into the program) List in order of preference all drugs used or tried; past or present (This MUST be complete)

Education Information Section

Medical Information Section

This party will sign an affirmation that they will pay for the meds.

Medical continued: Allergies: Are you allergic to:

Medical Continued: Injuries and Surgeries Information

SURGERY

Mental Health Information

On the following scales 1) being No problem or Not motivated to 10) Very serious or Very motivated:

AFFIRMATION

This is a good place to save and take a break, the next section is your autobiography and requires 1000 to 1500 words

Autobiography

Outline for Applicant’s Autobiography

It would be impossible to overestimate the importance of being thoroughly and completely honest with yourself and others. Each client is required to write an autobiography including a history of their substance use, mental health issues, and goals for treatment and recovery.

Issues to be covered in your autobiography are:

Describe your substance use history, including what and how long you have used it.

Have you ever been in the hospital for mental health reasons? Explain in detail.

Have you ever tried to commit suicide?

Discuss any mental health issues including diagnoses and history.

List what medications you are taking and why.

Describe your present situation – be as specific as possible.

Why do you want to be admitted to FIRST?

Discuss specific changes you want to make in your life.

What goals do you want to achieve while at FIRST?

What are your goals for recovery?

How will you contribute to the program and your fellow residents?

Minimum Length: 1000 words

Your personal autobiography should be at least 1000 to 1500 words in length, and should be typed in chronological order as to how and when the events occurred.

ACCEPTANCE AND AGREEMENTS

Information for Applicants

Items to Bring

Necessary Items:

Suggested Items:

Items NOT to bring:

FIRST Inc. will not be responsible for items left after a resident leaves the program.

I understand that if I bring items other than those specifically listed above, the items will be disposed of at the time of my entry into the program. The list above is all-inclusive; there are no exceptions.

AUTHORIZATIONS TO RELEASE

INFORMATION

CRIMINAL JUSTICE SYSTEM REFFERALS

Name of program which is to exchange information:

Name or title of the person(s) or organization(s) with which the disclosure is to be made:

Purpose or need for the disclosure:

Extent or nature of information to be exchanged:

General Consent

Name of program which is to exchange information:

Name or title of the person(s) or organization(s) with which the disclosure is to be made:

Purpose or need for the disclosure:

Extent or nature of information to be exchanged:

AGREEMENT TO ACCEPT TREATMENT AT

FIRST AT BLUE RIDGE

By signing and dating below, I am acknowledging and agreeing to the above and confirming that I desire the treatment provided by FIRST at Blue Ridge.

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