Admission Application


Blueprints For Recovery Application for Admission P.O. Box 10878• Prescott, AZ 86304• (888) 391.9772
www.BlueprintsforRecovery.com

Application Instructions
We appreciate, value, and welcome your interest in Blueprints for Recover as well as beginning the recovery process.

Please complete the following application as thoroughly and honestly as possible. The information presented will help us in determining the appropriateness of our program for the applicant. Should the applicant be accepted and admitted, the accuracy of the information in each section will assist us in effectively understanding and helping the applicant with their recovery process.

Admission Requirements and Criteria
Blueprints for Recovery is not a medical facility. In the event that the applicant is not medically appropriate for admission, Blueprints for Recovery will require the applicant to enroll in a medical detoxification program. We will help facilitate an appropriate referral. Blueprints for Recovery does not accept any responsibility for the transportation, monitoring, or making arrangements for the applicants medical care but we are here to help you with that process.

Blueprints for Recovery is a voluntary program that challenges young men to participate in their recovery process. We are committed to this process and in creating a safe environment for the applicant to flourish in their recovery.

Additionally, it is understood that if the applicant is unwilling to participate, refuses to engage in the curriculum, or recalcitrant at any time during their tenure, Blueprints for Recovery reserves the right to immediately discharge the participant. In that situation, we assume no responsibility for the transportation, monitoring, or making arrangements for transfer to another facility. Upon completion of the application, please fax to (928) 277-4349 for review.

Applicant's Information

Financial Sponsor Information

Father's Information

Mother's Information

Source Information

How did you first come to hear about Blueprints for Recovery?

If you found Blueprints for Recovery on the internet, please list key words/phrases that you used to find us:

Please tell us of any specific person who referred you to us.

Do we have your permission to contact this person?

Yes No 

Emergency Contact Information (if other than applicant's parents(s))


Therapeutic and Medical History

Professional Involvements

Please list all mental health professionals and treatment programs that the applicant has been involved with. Please indicate those professionals and/or organizations that ongoing involvement with the applicant and/or family is required.


Update:

Yes No 

Update:

Yes No 

Update:

Yes No 

Comments

Significant Medical History

Does the applicant have any medical or physical limitations or diagnoses?

Yes No 

If yes, what?

Is the applicant on a special or restricted diet for medical or personal reasons?

Yes No 

If yes, what?

Does the applicant have any allergies?

Yes No 

If yes, what?

History of surgeries/broken bones?

Yes No 

If yes, what?

Has the applicant ever been hospitalized other than for the previously mentioned?

Yes No 

If yes, what?

Addiction

Please tell us about applicant's addiction: (drug of choice, frequency of use, length of time using)

Medication

Please use one section per medication:

Are you in agreement with current medication related to diagnosis?

Yes No 

Comments:

Emotional/Mental Health Inventory

Has the applicant been given a diagnosis by a qualified mental health professional?

Yes No 

Please use one section per diagnosis:

Please check any that apply to the applicant:

Depression Anxiety Hearing Voices Cruelty to animals Arson/fire setting Psychiatric hospitalization Running away Death of a family friend Death of a friend Arrested/On probation Violence towards others Suicide threat or attempt 

For any that were checked as applicable, please provide an explanation:

Legal History

Has the applicant ever been arrested? If yes, please provide an explanation.

Does the applicant have any pending charges or legal concerns? If yes, explain.

If applicable, please answer the following

Other Relevant Information

With whom is the applicant living with most recently?

Does the applicant have children?

Is the applicant adopted? If adopted, at what age? Has the applicant met biological parents?

Please explain the applicant's academic history (highest grade completion, performance, areas of interest or study)

Please explain the applicant's work history (places of employment, performance, areas of interest, skills, etc.)

Is there anything else we should know about the applicant?


Contact Us

Blueprints For Recovery