Thank you for your interest in Vita Nova Residential Treatment, part of True North Recovery, Inc.

Application Checklist

• Application (Client Profile 5 pages)
• Health Screening Form/Clearance to Participate (3 pages) **To be completed by a Health Care Provider within the past 45 days.
• Behavior Health Assessment (3.1 recommended level of care, and within the past 6 months)
• Release of Information (ROI)—for any referring providers OCS, Medical Doctors, Probation,
• Case Management etc. (please use our form)
• Contact Preference Form
NOTE: A completed packet is to include all documents listed on the Application Checklist.

Please contact (907) 313-1333 for questions regarding the application process.No application will be processed without all required documents. After completing your online application, you will need to print the Vita Nova application packet, this will include the needed ROI’s, health screening form and your list of approved and not approved items. If you need assistance with completing the printable packet, please contact 907.313.1333 to schedule a meeting with one of our case managers.

Residential Treatment Application
Instructions: To help guide your treatment in a manner that best meets your unique needs, please include the following information:
Full Legal Name*
First Last
DOB*
MM slash DD slash YYYY
SSN*
What is your maiden name? (If applicable)
Mailing Address*
Street Address City State ZIP Code
Home Phone
Cell Phone
List all Medications / Supplements / Vitamins you are currently taking:*
What date are you available to enter treatment?*
Billing Information / Authorization
Expected Payment Source (check all that apply):*
- Insurance
- Medicaid (includes Denali Kid Care)
- Self-Pay
- Other
Medicaid ID number:
CLIENT INFORMATION
Are you female (defined as having female reproductive organs)?*
- Yes
- No
Are you male (defined as having male reproductive organs)?*
- Yes
- No
Marital Status:*
- Married - Living as married
- Widowed/Widower
- Separated - Single (never married)
- Divorced
If Divorced - How Long?*
Race:*
- Aleut
- American Indian
- Asian
- Athabascan
- Black/African American
- Caucasian
- Hispanic
- Inupiat
- Tsimshian
- Native Hawaiian
- Tlingit
- Pacific Islander
- Yupik
- Other Alaska Native
- Other
If other please describe:
Legal Status:*
- None/No involvement
- 30 Day Commitment
- 90 Day Commitment
- 180 Day Commitment
- Emergency Commitment
- Office of Children Services
- Probation/Parole
- Informal Probation
- Incarcerated
- Community Sentencing
- Case Pending
- Court Ordered for alcohol treatment
- Court Ordered for mental health treatment Incarcerated
- Court Ordered for observation and evaluation Case Pending Deferred Prosecution
- Other
If other describe:
Military Status:*
- Never in Military
- Active duty (combat)
- Active duty (non-combat)
- Reserves (combat)
- Reserves (non-combat)
- Retired (combat)
- Retired (non-combat)
- Military Dependent
Have you ever been charged with a crime against a vulnerable person (child, elderly, or disabled)? YES / NO - If yes, please explain:*
Are you required by state or federal authorities to register as a sexual offender? YES / NO - If yes, please explain:*
How do you like to learn? (Check all that apply)*
- Watching
- Reading
- Listening
- Doing
What language is spoken primarily in your home?*
Do you speak a second language?*
- Yes
- No
If YES what language?*
Do you need an interpreter?*
- Yes
- No
Do you have special needs? (Check all that apply)*
- None
- Diagnosed memory and/or learning disabilities
- Severe Hearing Loss or Deaf
- Do you need auditory aids?
- Hearing aids
- Other
If other please describe:
List any visual impairments: (Check all that apply)*
- None
- Visual Impairment or Blind
- Do you need visual aids?
- Magnifying glasses
- Large print material
- Braille
- Other
If other please describe:*
List any physical limitations (check all that apply)*
- None
- Major Difficulty in Ambulating
- Physical limitations
- Diagnosed chronic sleep problems
- Organic brain disorder
- Traumatic Brain Injury
- Other
If other please describe:
What problem(s) brought you here today? (check all that apply)
- Alcohol problems
- Domestic violence
- Depression
- Drug problems
- Marital/Relationship Problems
- Psychological/emotional
- Alcohol/drug problems
- Family problems (non-marital)
- Suicide Attempt/Threat
- Legal problems
- Social/Interpersonal
- Victim of Child Abuse
- Victim of Sexual abuse
- Perpetrator of Sexual Abuse
- Perpetrator of Child Abuse
- Other
If other please describe:*
What goals would you like to achieve to improve your quality of living? (check all that apply)*
- Regaining custody of children/parenting issues
- Lack of stress management skills
- Social network problem (I.e. drug using friends/acquaintances)
- Education issues
- Lack of sober, social support
- Poor communication skills and/or poor
- Lack of self-esteem, self-confidence, or positive identity
- Conflict management skills
- Lack of structure and time management skills
- Housing
- Financial concerns or unpaid bills
- Other
If other please describe:*
FAMILY / SOCIAL HISTORY
Where do you live currently?*
Monthly household Income:*
Living Arrangements:*
- Alone
- With Children
- With Spouse/Significant Other
- With Parents
- With Other Relatives
- With Non-Related Person
- Homeless
- Incarcerated
- Shelter
Where and with whom will you live after completing treatment?*
Are you Pregnant?*
- Yes
- No
If YES what is your due date?
Do you have children?*
- Yes
- No
Are you the primary caretaker of your children?
- Yes
- No
If YES, have you arranged for childcare while you participate in treatment?
- Yes
- No
SPIRITUALITY
During the past month, how would you rate your sense of connectedness, spirituality or relationship with a higher power?*
- Excellent
- Good/Improving
- Fair/Not Changing
- Not Good
- Very Bad
- Other
How important is spirituality in your life?*
- Very important
- Somewhat Important
- Not Very Important
- Not At All Important
How often do you spend time on regular spiritual practices?*
- Every day or almost every day
- Several times a month
- Occasionally
- Very rarely
- Not at all
What is your religious affiliation, if any?*
Is there anything else that you would like us to know about your religious/cultural/spiritual practices?
SUBSTANCE USE
What is your drug of choice?*
When is the last time you used alcohol and/or other drugs?*
Are you currently injecting drugs?*
- Yes
- No
Do you use Tobacco Products?*
- No
- Cigarettes
- Smokeless tobacco (chew)
- Other
List your goal or goals for the future:*
Describe your personal challenges or things that make it difficult to reach your goals:*
What would you like to gain from treatment that would support your recovery goals?*
MENTAL HEALTH SUMMARY
Prior mental health history: (Check all that apply)*
- No history
- Counseling
- Medication management
- Hospitalization
Are you currently involved in mental health services?*
- Yes
- No
If YES, with whom?
During the past 12 months, did you take any medication that was prescribed to treat a mental health or emotional condition?*
- Yes
- No
If YES, please list medication and dosage:
Dates of prior mental health hospitalizations:
PHYSICAL HEALTH SUMMARY
Have you undergone, or are you currently undergoing hormonal therapy for transgender surgery?*
- Yes
- No
If yes, is this process completed (physical surgery, hormonal treatment, and emotional counseling components)?
If YES when was this process completed?
Do you intend to undergo hormonal therapy for transgender surgery while admitted to this program?*
- Yes
- No
In general, how would you describe your current health?*
- Excellent
- Very Good
- Good
- Fair
- Poor
Have you had any unplanned weight changes in the last 12 months?*
- Yes
- No
If YES, please explain:
Do you have nutritional concerns?*
- Yes
- No
If YES, please explain:
Do you have a primary medical provider?*
- Yes
- No
If YES, Who?
If you do not have health benefits, what is your financial plan for prescribed medications?
Do you have allergies to foods or medications?*
- Yes
- No
If YES, please list:
Do you have any chronic health or pain issues?*
- Yes
- No
If YES, please explain:
Consent*
By checking this box I state that I am able to self-administer the medication(s) prescribed to me, including if needed, the physician approved over-the-counter medications. It will be my responsibility to ask staff to retrieve my medication from the secure area when it is time for me to take my medication. I will assist in the documentation process by documenting each time I take medication on the “Self-Administration of Medication Form”.
Signature*
Type Name*
First Last
Date*
MM slash DD slash YYYY
CONSENT FOR DISCLOSURE OF INFORMATION
Consent*
BY CHECKING THIS BOX I REQUEST/AUTHORIZE TRUE NORTH TO DISCLOSE MY INFORMATION TO AND/OR OBTAIN INFORMATION REGARDING MYSELF USING THE FOLLOWING CONTACT.
Name
First Last
Mailing Address
Street Address City State ZIP Code
Email
Message Phone (TNR will leave messages at this number)
Fax
PLEASE LIST ALL OTHER NUMBERS THAT WE MAY USE TO CONTACT YOU
#1*
First Last
Relation*
OK TO LEAVE MESSAGE?*
- Yes
- No
#2*
First Last
Relation*
OK TO LEAVE MESSAGE?*
- Yes
- No
#3*
First Last
Relation*
OK TO LEAVE MESSAGE?*
- Yes
- No
#4
First Last
Relation
OK TO LEAVE MESSAGE?
- Yes
- No
Consent*
I understand that the information in this correspondence may contain information relating to my substance use diagnosis and/or treatment, mental health diagnosis and/or treatment, and/or Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS)
Consent*
I understand that my alcohol and/or drug treatment records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. Pts. 160 & 164, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand that the agencies identified above may not condition my treatment on whether I sign a consent form, but that in certain circumstances I may be denied treatment if I do not sign a consent form.
Consent*
I understand and consent to the use of all electronic communication, text messaging and email and that they all have potential security risks.
Client Signature*
Type Name*
First Last
Date*
MM slash DD slash YYYY
SIGNATURE OF PARENT GUARDIAN/REPRESENTATIVE
Type Name
First Last
Date
MM slash DD slash YYYY
WITNESS SIGNATURE
Type Name
First Last
Date
MM slash DD slash YYYY
DISCLOSURE OF ALCOHOL AND DRUG TREATMENT INFORMATION I UNDERSTAND THAT MY ALCOHOL AND/OR DRUG TREATMENT RECORDS ARE PROTECTED UNDER THE FEDERAL REGULATIONS GOVERNING CONFIDENTIALITY AND DRUG ABUSE PATIENT RECORDS, 42 C.F.R. PART 2, AND THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (“HIPAA”), 45 C.F.R. PTS 160 AND 164, AND CANNOT BE DISCLOSED WITHOUT MY WRITTEN CONSENT UNLESS OTHERWISE PROVIDED FOR BY THE REGULATIONS.

I UNDERSTAND THAT I MAY BE DENIED SERVICES IF I REFUSE TO CONSENT TO A DISCLOSURE FOR THE PURPOSES OF TREATMENT, PAYMENT OR HEALTH CARE OPERATIONS, IF ALLOWED BY STATE LAW. I WILL NOT BE DENIED SERVICES IF I REFUSE TO CONSENT TO A DISCLOSURE FOR OTHER PURPOSES.

I HAVE HAD EXPLAINED TO ME AND FULLY UNDERSTAND THIS REQUEST/AUTHORIZATION TO RELEASE AND/OR OBTAIN RECORDS AND INFORMATION, INCLUDING THE NATURE OF THE RECORDS, THEIR CONTENTS, AND THE CONSEQUENCES AND IMPLICATIONS OF THEIR RELEASE. I UNDERSTAND THAT ONCE MY INFORMATION IS RELEASED, TNR CANNOT PREVENT THE REDISCLOSURE OF THAT INFORMATION, HOWEVER DOES PROVIDE A STATEMENT OF PROHIBITION AGAINST REDISCLOSURE OF PROTECTED HEALTH INFORMATION WITH DISCLOSURES MADE.

I UNDERSTAND THAT I MAY REVOKE A CONSENT IN WRITING AT ANY TIME, EXCEPT TO THE EXTENT THAT ACTION BASED ON THIS CONSENT HAS ALREADY BEEN TAKEN. SEE RECEPTION FOR INSTRUCTIONS TO REVOKE A CONSENT. IF TREATMENT IS MANDATED AS PART OF PROBATION REQUIREMENTS, A CONSENT MAY NOT BE REVOKED UNTIL CONDITIONS OF PROBATION ARE MET OR PROBATION ENDS.

I HAVE A RIGHT TO RECEIVE A COPY OF THIS SIGNED AUTHORIZATION. I ALSO UNDERSTAND THAT UPON MY WRITTEN REQUEST, TNR MUST PROVIDE A RECORD OF DISCLOSURES MADE FOR LEGAL, ADMINISTRATIVE OR QUALITY ASSURANCE PURPOSES.
NOTICE PROHIBITING REDISCLOSURE OF ALCOHOL AND DRUG TREATMENT INFORMATION This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR part 2). The federal rules prohibit you from making any further disclosure of information in this record that identifies a patient as having or having had a substance use disorder either directly, by reference to publicly available information, or through verification of such identification by another person unless further disclosure is expressly permitted by the written consent of the individual whose information is being disclosed or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose (see § 2.31). The federal rules restrict any use of the information to investigate or prosecute with regard to a crime any patient with a substance use disorder, except as provided at §§ 2.12(c)(5) and 2.65.
Signature of Client*
Type Name*
First Last
Date*
MM slash DD slash YYYY
Email
This field is for validation purposes and should be left unchanged.