Cayuga Addiction Recovery Services SUPPORTIVE LIVING PROGRAM Dorothy Radcliff 334 W. State Street Ithaca, NY 14850 (607) 2735500 FAX (607) 2731277 Application for Admission PART 1 TO BE COMPLETED.
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How to fill out the NY Cayuga Addiction Recovery Services Supportive Living Program Application For Admission online
Completing the NY Cayuga Addiction Recovery Services Supportive Living Program Application For Admission online is an essential step for individuals seeking support in their recovery journey. This guide will walk you through each section of the form, providing clear and supportive instructions to help you navigate the application process effectively.
Follow the steps to complete your application online.
- Press the ‘Get Form’ button to access the application form and open it in your preferred document editor.
- Begin with Part 1, which should be completed by the referral source. Fill in the client's demographics, including the client’s name, date of birth, gender, Social Security number, and race/ethnicity. If applicable, indicate if the client is an intravenous drug user.
- Continue in Part 1 by providing the anticipated discharge date and the client’s primary language. Answer whether this date is flexible, and complete the home county and zip code details.
- Provide the current address along with veteran status and the client’s phone number. Include financial information, specifying the source of payment for services and any relevant details.
- In Part II, the client will indicate if they have been previously served by Cayuga Addiction Recovery Services and detail any past treatment experiences.
- Proceed with the education and vocation section, indicating the highest grade completed and the date of last employment.
- Fill in the marital status, number of children, and any information regarding child custody or open Child Protective Services (CPS) cases.
- Address the personal narrative section by explaining in your own words why you believe you need the Supportive Living Program and what goals you aim to achieve.
- List any medical needs and medications currently being taken. Specify adherence to prescribed medication.
- Discuss your sober support system and provide the name of your sponsor, including any support meeting attendance.
- Detail any legal information, including current legal status and a summary of your legal history if applicable.
- Review your application for completeness and accuracy before signing and dating the application at the bottom.
- Once all sections are completed, save changes to your application. You may then download, print, or share the document as needed.
Start completing your application online today to access the support you need.
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