COVER PAGE Please check which level of care to which the applicant is applying. Complete referral packages* should be faxed to (716) 362-0221 or scanned and emailed to intake@cazenoviarecovery.org. Thank you. Intensive Residential Rehabilitation (Women) Intensive Residential Rehabilitation (Men) Madonna House Turning Point House 5586 Niagara St. Ext. 9136 Sandrock Rd. Lockport, NY 14094 Eden, NY 14057 Applicants may be single women, pregnant women, or women with children preschool-age or younger Community Residential Erie County Casa Di Vita (Women) Cazenovia Manor (Men) Unity House (Homeless men) 200 Albany St. 486 N. Legion Dr. 923 Sycamore St. Buffalo, NY 14213 Buffalo, NY 14210 Buffalo, NY 14212 Verification of homelessness required Niagara County Somerset House (Women) Sundram Manor (Men) 7397 Lake Rd. 431 Memorial Pkwy Appleton, NY 14008 Niagara Falls, NY 14303 Liberty Hall PO Box 1500 Batavia, NY 14021 Please send applications for Liberty Hall directly to the program s address or fax, which is (585) 343-3785. Applications for Liberty Hall should not be sent to the email address or fax number listed at the top of this page. Supportive Living (Erie County) Apartments located in Buffalo and surrounding areas Supportive Living (Niagara County) Apartments located in Niagara Falls and Lockport. Limited beds are available in both counties for parents with children preschool-age or younger *Complete referral packages must include the following: Application Psycho-social assessment Treatment plan Verification of homelessness (required for Unity House applicants) Confirmations from Social Services or Social Security Mental health evaluation, if applicable Consent forms (Social Service, referring agency, LOCADTR etc.) Medical history, physical, medical clearance for communicable diseases, and lab work with a PPD test and verification 1
INTRODUCTION Thank you for your interest in Cazenovia Recovery Systems. We look forward to assisting you in your continued recovery. You should be proud that you are open to receiving treatment. Please answer the questions below to the best of your ability. We understand this application asks many questions of you. This is done so that we can provide you with the best treatment possible so that you can build a future, achieve your dreams, and reach your goals. During your stay with us, we hope to provide you with services and treatment that are supportive and encouraging. We will assist you in finding resources for which you qualify to help make your recovery a positive journey toward your future. APPLICANT INFORMATION Name: Phone: Street address (prior to treatment, if applicable): City: County: State: Zip: What are the reasons why the applicant cannot return to the above address? Is the applicant homeless or at risk for homelessness? If yes, please explain: D.O.B. S.S.N. Medicaid Number: VETERAN STATUS Is the applicant a Veteran? If yes, please answer the following: Branch: Discharge Type: Years of Service: Did the applicant serve in the reserves? If yes, were they deployed? Does the applicant receive VA funding? If yes, how much per month? 2
SUBSTANCE HISTORY Does the applicant have a substance disorder diagnosis? If yes, list DSM / ICD Code: Code Description Substance Type Onset Frequency Route of Ingestion Date of Last Use TREATMENT HISTORY (e.g. Detox, Outpatient, Inpatient, Community Residence, etc.): Facility Name Type Dates Successful Completion 3
MENTAL HEALTH Does the applicant have a mental health diagnosis? If yes, please explain below: Diagnosed by: Date of diagnosis: Is the applicant currently receiving mental health treatment? If yes, who is the provider? Does the applicant have previous mental health treatment, including hospitalization? If yes, please answer the following: Events leading to mental health treatment Program Dates / Length of Stay Does the applicant have a history of suicide attempts? If yes, please explain below: 4
MEDICAL Does the applicant have a Primary Physician? If yes, please provide the following: Name of Physician Address Phone No. Conditions being treated Date of last physical exam / lab / blood work: Date of last TB test: List any physical disabilities or limitations: Is the applicant currently being treated for any communicable disease? If yes, explain below: Does the applicant have any previous head injuries? If yes, please explain circumstances: Has the applicant ever been linked with a Health Home? If yes, provide the following: Name of Health Home Health Home City Dates of Enrollment If the applicant is female, is she pregnant? N/A If yes, please answer the following: When is her due date? Is she receiving prenatal care? If she is receiving prenatal care, where? MEDICATION Current Medication Dosage Prescribing Doctor Reason for Medication Is the applicant prescribed any Medication-Assisted Treatment medications? If yes, please complete the following: Current Medication Dosage Prescribing Doctor Phone Number 5
LEGAL Is the applicant mandated to this level of care? If yes, by whom: Please provide any legal entities with which the applicant has involvement: Entity (Drug Court*, Probation, etc.) Jurisdiction Contact Person Contact Number If you are a Drug Court making this referral, please include the applicant s NYS ID and a criminal justice release with the completed application. Does the applicant have any pending court appearances? If yes, please describe below: Date Time Location Reason for Appearance Does the applicant have outstanding warrants? Unknown Does the applicant have a history of assault? Unknown Has the applicant accidentally or intentionally set fires? Unknown Has the applicant been arrested for or convicted of arson? Unknown Has the applicant ever been convicted of any crimes? If yes, provide nature of arrests: Has the applicant ever been incarcerated? Unknown Does the applicant have any history of rape, sexual abuse, or violent crimes against a person? If yes, please explain below: Does the applicant have an order of protection? Unknown 6
FINANCIAL Does the applicant currently receive Social Service benefits? If yes, please provide: From which county? Current monthly amount: Does the applicant currently receive SSI / SSD benefits? If yes, please provide: Self-Payee Rep Payee Payee Name: Phone No.: Payee Address: Current monthly income received from SSI / SSD: Has the applicant ever been sanctioned/refused Social Services or Social Security benefits? If yes, please explain: Does the applicant have any other sources of income? If yes, please explain: EDUCATION Proof of income must be submitted with the application. What is the highest grade level the applicant has completed? High School Diploma GED Some college College degree Please list any diplomas, degrees, certificates, and licenses below: FAMILY What is the applicant s marital status? Single Married Divorced Estranged Widowed Does the applicant have any children? If yes, do they have custody? If yes, how old are the children? If the applicant is applying to Madonna House or Supportive Living, do they hope to have children reside with them while in the program? N/A 7
SIGNATURES By signing below, you (the applicant) agree to and understand the following: 1. If you are receiving SSI/SSD or other forms of income, a sliding fee scale and financial agreement will be developed and agreed upon prior to your admission. 2. Cazenovia Recovery strives to house individuals who have prior histories of homelessness. If this applies to you, you may be asked to verify your homelessness status. 3. To ensure the safety of all applicants, current residents, and staff, you may be asked to consent to a criminal background check. 4. Cazenovia Recovery Systems cares about the health of each and every one of our residents. To ensure that our programs are healthy places to live, all of our facilities are no smoking. Applicants with nicotine dependence will be provided with smoking cessation information, treatments and groups. 5. For applicants applying to Madonna House: Mothers in recovery may need time to adjust to the program and to establish parenting skills they may need to develop. Because of this, children who are eligible for admission may not be admitted at the same time as their mother. Applicant s Signature: Date: Printed Name: Referring Staff s Signature: Date: Printed Name: Referring Agency Name: Contact Email: Phone: 8