The Haven | Enrollment

The Haven's Online Screening Form

Please fill out this questionnaire to determine eligibility for The Haven Program.
Clients are subject to a blackout period while initial program requirements are met.
The Haven Continuum of Care can be up to 1 year of services: Residential (up to 6 months) +
Outpatient (up to 6 months). Day passes can be earned after 45 days.
Smoking is not permitted. Vapes are allowed outside. Nicotine replacement is available.
MAT (suboxone/methadone) must be Project Reality participant.
MAT (Sublocade and Vivotrol) are available through The Haven's APRN.
Suboxone, Gabapentin/Lyrica, Muscle Relaxers, Stimulants, are not permitted.
Cell phones are not permitted.
Callbacks from The Haven will show up as 385-210-1907 on caller ID

Are you currently at any of these facilities?:
Full Legal Name: Email: Date of Birth: Gender Identification: Your phone number / alternate phone number: Your email address:
What services are you seeking?
Residential
Outpatient (Level of care assessment required)
Sober Living

If you were referred to us by an an agency please specify. Otherwise please tell us how you have heard about The Haven.*:

Smoking is not permitted. Discreet disposable vapes are allowed. Nicotine patches, gum, and lozenges are available by prescription via Medicaid.*:

If you receive methadone services, those services must be provided by Project Reality while in residential treatment at The Haven.*:

If you are currently prescribed suboxone and are entering residential treatment, you will be required to utilize the sublocade injection. If you are interested in suboxone/sublocade, and not currently prescribed, you will need to seek those services prior to admission.*:

Certain medications are not permitted at The Haven, and you will be expected to discontinue or taper off them if admitted into treatment. These include: Gabapentin/Lyrica Suboxone Opioid pain medications Medical Cannabis Benzodiazepines Certain sleep medications (Ambien, Lunesta, etc.) Muscle relaxants (Soma, Robaxin, Flexeril, etc) Stimulant medications (Adderal, Ritalin, etc.) This list is not exhaustive, and all of your medications will be reviewed to see if they are allowable.*

Emergency-contact name, relationship, address, and phone number*:

Current Housing Situation: Please list any current or recent insurance:
Do you have a spouse or children that are currently or will be on your DWS/Medicaid case?*:

What is your substance(s) of choice?: Date of last use, and substance used:
Please list all substances used in the last 30 days: Cannabis IV Smoke Oral/Ingest Snort/Nasal Cocaine IV Smoke Oral/Ingest Snort/Nasal Inhalants IV Smoke Oral/Ingest Snort/Nasal MDMA IV Smoke Oral/Ingest Snort/Nasal Kratom IV Smoke Oral/Ingest Snort/Nasal Spice IV Smoke Oral/Ingest Snort/Nasal Methamphetamine IV Smoke Oral/Ingest Snort/Nasal Bath Salts IV Smoke Oral/Ingest Snort/Nasal Heroin IV Smoke Oral/Ingest Snort/Nasal Fentanyl IV Smoke Oral/Ingest Snort/Nasal Prescription Opiates IV Smoke Oral/Ingest Snort/Nasal GHB IV Smoke Oral/Ingest Snort/Nasal Ketamine IV Smoke Oral/Ingest Snort/Nasal Rohypnol IV Smoke Oral/Ingest Snort/Nasal Over the Counter IV Smoke Oral/Ingest Snort/Nasal Alcohol IV Smoke Oral/Ingest Snort/Nasal Benzodiazepine IV Smoke Oral/Ingest Snort/Nasal Hallucinogens IV Smoke Oral/Ingest Snort/Nasal Vape / Nicotine IV Smoke Oral/Ingest Snort/Nasal
Have you ever overdosed in the past? If yes how many times and when was the most recent time?*:

Do you have a history of seizures? If yes, please describe.*:

Do you have any major or ongoing medical needs, including dental work, that require appointments outside of treatment? If yes, please describe.*:

The Haven is a high functioning program. Do you have any physical limitations that limit daily activities, like walking up stairs, around the block, participating in chores, or require assistive devices like a walker, wheelchair, or crutches? If yes, please describe.*:

Please list all allergies to food, medication, and environment *:

Are you or have you been pregnant in the last 90 days?:

Please check all mental-health conditions you have been diagnosed with or have symptoms of:
Anxiety Depression Post Traumatic Stress Disorder Bipolar 1 Bipolar 2 Borderline Personality Disorder Schizophrenia Schizoaffective disorder Other Unspecified Personality Disorder
Other:

Are you currently seeing or hearing things others do not appear to see or hear?*:

If yes, please describe:

Please list any history of suicide attempts *:

Within the last 30 days have you had thoughts of harming either yourself or others?:

Other:

Do you have a history of violence? Please explain. *:

Please describe any criminal charges you have had, and the lengths and types of incarcerations (jail or prison)*:

Are you currently charged with, or have you ever been convicted of, any of the following: Any sexually-related offense. Kidnapping. Child abuse.

Please add any attorney information and/or upcoming court dates here*:

Please list prior treatment programs. PLEASE INCLUDE*: Name of program; Dates of attendance; Reasons for leaving/ending treatment; Brief description of your experience with each program.

What is motivating you to seek treatment at this time?*:

What do you hope to achieve by going through treatment? *:

Why do you want to come to The Haven? Please be detailed in your response.*:

Any additional comments or information may be added here:

Name, relationship, and contact info of person submitting form (if other than self).:

Disclaimer Any false or misleading information provided in this form prior to admission may result in discharge from services

Enrollment

The Haven's Online Screening Form

OUR MISSION

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