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
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
Are you currently at any of these facilities?:
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