Newland Application

Your Personal Information

Name*

First Name Last Name

Date of Birth*

MM slash DD slash YYYY

Gender Assigned at Birth?*

Male

Female

Do you have Colorado Medicaid, or Private Insurance?

* Please list your Medicaid ID number, or your Insurance member ID.

Phone Number*

Please enter a valid phone number

Email*

example@example.com

Emergency Contact*

First Name Last Name

Emergency Contact Phone Number*

Please enter a valid phone number.

Current living situation*

Alone

With Family

In Transitional Housing

Homeless

Are you currently receiving SNAP food benefits?

Yes

Employment:*

If employed, please provide your job title and employer:

Do you have a valid driver's license?*

Yes

Do you own a vehicle?*

Yes

What were your substances of choice (including drugs and alcohol)?*

What is the longest length of time you have ever been sober?*

When did you last use drugs or alcohol?*

Are you currently in a treatment facility?*

If yes, please provide the name and location of the facility, the length of your stay, and the expected completion date:*

Have you ever been diagnosed with a mental illness?*

If Yes, is it managed?

Have you ever attempted self-harm?*

If Yes, what method did you try, and how long ago did this occur?*

Are you currently prescribed any medications including MAT (medication-assisted treatment, such as Suboxone, Methadone, or Naltrexone)?*

If Yes, please list all your medications including dosage information.*

Do you have any ongoing health issues or disabilities that require accommodation?*

If Yes, please describe:*

Are you currently required, or will you be required, to report to probation, parole, or any court?*

If yes, please provide the name, contact information, and county of your reporting officer or agency.*

Have you ever been convicted of a felony, including assault, arson, or sexual abuse?* *All applicants may be subjected to a sexual registry search.

If Yes, please explain.*

What times are you available for a phone interview? (Select all that apply)*

If required, what are a couple days and times you are available for a phone interview? (Select all that apply)*

Name of Referral Source

First Name Last Name

Email of Referral Source

example@example.com

Do we have your permission to be in contact with your referral source?*

* Do you agree to attend voluntary daily treatment, and peer coaching while you are a member of the home?