How long at this address? *
Current contact phone *
Email *
Social Security Number: *
Driver's License Number: *
Religious preference (optional)
Emergency Contact Name: *
Emergency Contact Phone: *
Emergency Contact's Relationship to you: *
Referred by. If not referred, how did you hear about Pathway?: *
Briefly explain why your job is at risk:
Where and what are you studying?
What is your highest level of education? *
What dates were you a student? (Approx. is OK) *
What did you study? ("General Studies" is OK.) *
Briefly describe your last two jobs. Provide dates and your duties. Approx. dates are OK. *
Briefly list and describe your two closest relatives and current living situation *
Briefly list and describe your two most current treatments for substance abuse. *
Describe yourself when you were using: *
When was your last period of abstinence? How long did it last? How did you achieve this abstinence? *
Have you attended 12-Step meetings? If so: which ones, when, and for how long? *
Have you ever thought about or attempted suicide? If so, give details. *
Do you have any history of family abuse, either as abused or abuser? If so, give details. *
Have you ever been arrested? If so, give details, including criminal record. *
Do you have any criminal charges pending? If so, give details. *
Do you have any emotional problems? If yes, give details. *
Do you currently take any prescription medication? If so, list prescriptions. *
Do you currently have any medically-mandated dietary needs? If so, give details. *
Do you currently have any sexually-related problems? If so, give details. *
Do you currently have any physical limitations that would prevent you from doing necessary work at The Center? If so, give details. *
Please read the following: I do hereby consent and request treatment from The Center for the above described problems. Treatment may include individual, group, or family counseling, referral, counseling – cognitive therapy, 12-step program, or other appropriate services. I understand that it is my responsibility to read these rights and if I have any questions concerning them, I may discuss these concerns with my counselor. ***If you agree, type your name as an electronic signature: *
Please read the following: Agreement as to status and responsibility for payment of incurred medical expenses. As a voluntary participant in the program and critical to its therapy and counseling procedures, I understand that the program mandates my performing various manual labor tasks. I further understand that in performing such tasks, I am neither an employee nor an independent contractor rendering services to The Center. Accordingly, I understand and agree that there is no employer/employee relationship between The Center and myself and that I am not a covered party under the Illinois Worker’s Compensation Act or The Center’s Worker’s Compensation policy. Further, as a non-employee, I am not eligible for any employee benefits or amenities which The Center provides its employees. Additionally, as such participant, my voluntary performance of such tasks do not place me in the status of a “Center volunteer," for membership purposes. Since, in the event of injury or other medical need, I am fully responsible for providing my own medical payment, or am covered under another’s policy, I hereby certify that the following person will assume responsibility for payment of my medical expenses in the event of need: ***If you agree, type in your name, or the other responsible party's name, for medical expenses: *
Please read the following: I FURTHER CERTIFY: As to the correctness of the designation of the person who will resume responsibility for payment of medical expenses, and agree to subsequently provide any additional information requested, relative to the ability an assumption of responsibility of such person. Further, I understand that should The Center at any time determine, in their sole discretion, that I am unable to provide assurance to The Center of my ability to pay for my medical cost and expenses, as herein above mentioned, The Center shall have the right to immediately terminate my participation in the program. ***If you agree, type your name as an electronic signature: *
Please read the following: As a participant in the program, I acknowledge that use of the facilities, equipment and other assets of the Community Center Foundation, “The Center”, or located on its premise, involves exposure to potential hazards including but not limited to cuts, scrapes, animal bites, highway crossing, poison ivy and water accidents. While The Center attempts to reduce or avoid such hazards through instruction and safety procedures, the undersigned understands that all risk of danger or injury cannot be precluded, and specifically assumes all risk of injury in connection with use and handling of horses, owned and non-owned, stabled and/or exercised on premises or elsewhere, and with the use of equipment and tools, or the performance of task or duties as such participant. Accordingly, and as a condition of acceptance in the program at The Center, the undersigned does hereby release and discharge The Center, its staff, employees, members and invitees from all claims of any kind or character which the undersigned might have against The Center because of any injury which may be sustained, while engaged in said task, duties, or use or while participating in any functions of The Center or while on The Center’s premises. And said undersigned does expressly stipulate and agree to indemnify and to forever hold harmless said Center, its staff, employees, members and invitees against any and all claims, demands, actions, damages, costs, loss of service, expenses and compensation on account of or in any way growing out of injuries or death which may hereafter at any time be made or instituted against the said Center, its staff, employees, member and invitees, by the undersigned or by his/her legal representative or anyone on his/her behalf for the purpose of enforcing any claim for damages for injury sustained by him/her as a result of his/her use or presence on Center property or participation in a Center program or activity. I have read the foregoing indemnification agreement and fully understand it. ***If you agree, type your name as an electronic signature: *
Please read the following: I give The Center authority to perform a background check on me. ***If you agree, type your name Last Name/First Name/Middle Initial and fill out the other required fields: *
Social Security Number *
Date of Birth/Height/Weight/Hair Color/Eye Color *
All Previous Addresses last five (5) years. Write "None" if none. *
Any Other Names ever formerly used. Write "None" if none. *
READ CAREFULLY: I verify that I have not been a perpetrator of an indicated incident of child abuse or neglect pursuant to the Abused and Neglected Child Reporting Act; nor have I been involved in any offense concerning young people under the age of sixteen; nor have I been convicted of a felony. I hereby authorize The Center to conduct a search to determine the above. This authorization is given as part of my application for acceptance as a participant in the Pathway to Sobriety Program at The Center. All information relative to the background investigation is confidential and any dissemination will be in accordance with state and federal law. I certify that I have read and understand the foregoing language and understand that information developed as a result of my authorizing this investigation may be shared with The Center and its Executive Director. I further certify that the information on this form is true and correct. ***If you agree, type your name as an electronic signature: *
Please read the following: AUTHORIZATION FOR CONTACT AFTER DISCHARGE I hereby authorize the staff of The Center to contact me by telephone or letter to find out how I am getting along after discharge from the Pathway to Sobriety Program and to invite me to any alumni functions. ***If you agree, type your name as an electronic signature: *
Please read the following: THE CENTER’S “PATHWAY TO SOBRIETY” DISCLOSURE STATEMENT: The Center’s “Pathway to Sobriety” chemical dependency extended continuing care program is a comprehensive program of complementary applied strategies with the explicit intention of changing your thoughts, feelings, and behaviors, particularly in how you relate to drugs and alcohol. “Pathway to Sobriety” is a holistic approach that utilizes (1) a foundation of spirituality: bringing meaning, value and purpose to your life, (2) hard work in a positive, supportive, and drug and alcohol free living environment, (3) an active association with Alcoholics Anonymous; meetings, sponsorship, and 12-step work (this includes AA, NA, CA, among other 12-step programs), (4) The Center community living, participation, and service, as well as, (5) chemical dependence and mental health counseling; including individual and group counseling sessions to educate, plan and the practice of relapse prevention strategies for the establishment of sustainable life style that is free from the use of drugs and alcohol. While your “sobriety” is the aim of The Center’s “Pathway to Sobriety” program, it is believed that the near term establishment of simple abstinence from alcohol and drugs is not enough to sustain the full remission of your chemical dependence. A major revision of your lifestyle with a spiritual awaking to what brings meaning, value, and purpose to your life, and your action that demonstrates your commitment to honesty, humility, appreciation, and the figurative “killing” of self-centeredness is the transcending goal toward which this program aggressively works to help you progress. Your committed active participation in all aspects of this effort is essential to your success in movement toward that goal; progress not perfection. Your commitment to and full active participation and cooperation with all treatment and programming efforts is expected. You must demonstrate your sustained motivation for active positive change to be retained in this program. You are therefore asked to explicitly state your commitment to active participation in all aspects of this program and give your expressed consent to the aforementioned holistic treatment approach utilized by The Center’s “Pathway to Sobriety” program; including the designated counselors and auxiliary personnel, work site supervisors, lodge manager, and administration staff. ***NOTE: You do not have to sign this. You have the right to refuse to participate in The Center’s Pathway to Sobriety Program.*** I fully understand what I have just read and the expectations for my full engagement within The Center’s “Pathway to Sobriety” program. I do by my signature below attest to the understanding and offer my consent to The Center’s “Pathway to Sobriety” treatment program as outlined, free from any pressure to do so. ***If you agree, type your name as an electronic signature: *
You're almost done! Have a Pathway counselor type in his name below before pressing the "Submit" button. *
