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234-571-9503

info@restoreaddictionrecovery.com

2650 Sanitarium Rd., Akron OH 44312

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Restore Addiction Recovery has earned the 2023 Gold Seal of Transparency from Guidestar, the world's largest source of information on nonprofit organizations.

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If you need immediate assistance, call 800-357-8684 to speak to one of our staff members.

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If you have any immediate questions, call 800-357-8684 to speak to one of our staff members.

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Last Name*

Phone*

Email*

Address*

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Please fill out the form below to begin the intake process at Restore Addiction Recovery

1

Contact Info

2

Legal Info

3

Medical Info

"*" indicates required fields

First Name*

Last Name*

Current Age*

Date of Birth*

MM slash DD slash YYYY

Phone Number*

Where does the applicant live? Who does he live with?*

Is the applicant currently working and where?*

Insurance Provider (Medicaid, Private, None, Other)*

Date Last Used Substance*

Age Use Started*

Substances Currently and/or Previously Used (Select as Needed):

	Currently Use	Previously Used
Alcohol
Cocaine
Heroin / Fentanyl
Hallucinogens (LSD, etc.)
Inhalants (Glue, Gas)
Marijuana
Meth
Prescription Medications
Nicotine
Other

Has the applicant had heavy meth use in his past?*

Has the applicant received treatment prior? When, where?

Are there any current or pending legal charges?*

Yes

If you answered "yes", please state what type of crimes and how long ago:

Any history of violent crimes?*

Yes

Are there any active warrants?*

Yes

Is the applicant court-ordered to enter treatment?*

Yes

Is the applicant on Probation or Parole?*

Yes

Do we need to contact his Probation Officer?*

Yes

Does the applicant have a court date within the next 30 days?*

Yes

Is the applicant a registered sex offender or have arson charges?*

Yes

What is the applicant's driver's license status? Does he have a vehicle?*

Does the applicant pay child support?*

Yes

Is the applicant physically fit to work 8 hours a day?*

Yes

Is the applicant receiving disability or social security income?*

Yes

Does the applicant have any concerning or urgent medical conditions?*

Yes

Does the applicant have dental concerns?*

Yes

Does the applicant have dental concerns?*

Yes

Any current concerns regarding infections and/or Hepatitis C?*

Is the applicant on any psychotropic medications or coming off psychotropic medications?*

Has the applicant ever been diagnosed with bipolar disorder, borderline personality disorder, or schizophrenia?*

What medications is the applicant currently taking?*