RECOVERY CENTER STUDENT APPLICATION

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Boston University College of Health & Rehabilitation Sciences: Sargent College Center for Psychiatric Rehabilitation Stephanie Cummings, Administrative Manager Recovery Services Division 940 Commonwealth Avenue West Boston, Massachusetts 02215 T 617-353-1124 F 617-353-7700 www.bu.edu/cpr RECOVERY CENTER STUDENT APPLICATION Instructions: Please complete all parts of your Student Application Packet, and fax it to Stephanie Cummings at (617) 353-7700 or by email stephc13@bu.edu. After receiving your packet, she will contact before the start of the upcoming semester to arrange a tour and meeting here at the center. PART 1: CONTACT INFORMATION [Last Name] [First] [Middle Initial] [Street] [Apartment/Suite Number] [City/Town] [State] [Zip Code] Phone: [Home] [Cell] Birthday: Preferred Pronouns: [Month] [Day] [Year] [e.g. she/her/hers] *Recovery Center uses email and text messaging to communicate with students. These are not secure modes of communication. By checking this box, you are agreeing to receiving emails and text messages from the center. You are accepting and understanding the risk of having your association with the center, possibly compromised with the use of unsecure email and text messages. Initials Date: 1

PART 2: DEMOGRAPHIC INFORMATION 1. What is your gender identity? Female Male Female to male transgender (FTM) Male to female transgender (MTF) 2. What is your race? Hispanic or Latino Black or African American White Native American or American Indian Agender Other (please specify): I don t know the answer Asian/Pacific Islander Other (please specify): I don t know the answer 3. What is the highest degree or level of school you have completed? Some High School /GED 4-Year College Degree (BA, BS) High School Diploma/GED Some Graduate Coursework Some Undergraduate Coursework Graduate Degree (e.g. MA, MFA, PhD, MD) 2-Year College Degree (Associates) 4. What is your current marital status? Single/Never Married Married Separated 5. What is your current employment/ volunteer status? Employed Full-time (40+ hours per week) Employed Part-time (1-39 hours per week) Unemployed 6. What is your current religious affiliation? Christianity Judaism Buddhism Islam Hinduism 7. Military Status: No, Military Service National Guard Divorced Widowed Volunteer Full- time (25+ hours a week) Volunteer Part- time (1-20 hours a week) Agnosticism Unaffiliated Other (please specify): I don t know the answer Armed Forces Other (please specify): 8. Citizenship Status U.S Citizen by Birth (Native) U.S Citizen Naturalized Non-resident Visa type Exp. Date: Permanent Resident Undocumented, in process 9. What is your sexual identity? Heterosexual, or straight Homosexual gay or lesbian Bisexual Asexual Fluid(ity) Other( please specify): I don t know the answer 2

PART 3: EMERGENCY CONTACT INFORMATION Relationship: Relationship: PART 4: PROFESSIONAL SUPPORTS Primary Care Physician Medical Facility/Clinic/Program: Psychiatrist Medical Facility/Clinic/Program: 3

Name (Primary contact): Therapist or Counselor or Case worker Counseling Service: PART 5: CURRENT MEDICAL & MENTAL HEALTH CONDITIONS Current Medical Conditions AIDS/HIV Cognitive Anaphylaxis Anemia Angina Arthritis/Gout Artificial Heart Valve Asthma Blood Disease Breathing Problem Cancer Chest Pain Clinical Obesity Convulsions Diabetes Dizziness or Fainting Spells Ear Problems/Hearing Loss Emphysema Epilepsy or Seizures Eye Problems Heart Attack/Failure Hemophilia Hepatitis (A,B or C) High Blood Pressure High Cholesterol Irregular Heartbeat Kidney Problems Liver Disease Low Blood Pressure Lung Disease Osteoporosis Stomach/Intestinal Disease Stroke Tuberculosis Ulcers 4

Part 5: CURRENT MEDICAL & MENTAL HEALTH CONDITIONS Current Mental Health Conditions Alcohol/Substance Abuse Anxiety Disorder Autism Spectrum Disorder (ASD)/ Asperger s syndrome Attention Deficit/Hyperactivity Disorder (ADHD/ADD) Bipolar Disorder Depression Dissociative Disorder Hoarding Disorder Illness Anxiety Disorder (IAD) Obsessive-Compulsive Disorder (OCD) Panic Disorder Personality Disorder (Borderline, Antisocial, etc.) Post-Traumatic Stress Disorder (PTSD) Schizophrenia Seasonal Affective Disorder (SAD) Sexual & Paraphilic Disorder Sleep & Wake Disorder (Insomnia, Narcolepsy, etc.) PART 6: ALLERGIES & MEDICATIONS Allergies & Reactions Current Medications 5

PART 7: INTEREST & GOALS Please explain your interest(s) in Recovery Services at the Center: Please explain your recovery goals and discuss what kind of help and support you think you will need to accomplish those goals: 6

PART 8: Authorization for Two-Way Release of Information for Medical and Psychiatric Records 1. Name of person/facility/agency other than or at Boston University to receive or release information: ***insert contact relationship and name 2. Information I give permission to release or receive 3. This release will expire on If nothing is specified, it will expire when I am no longer receiving services at Boston University. I understand that I have a right to withdraw this release at any time. If I withdraw this authorization, I must do so in writing and present it to the address above. I understand that if I pull my release of this information, it will not apply to information that has already been given before I withdrew this permission. I understand that once the above information is disclosed to a person, facility or agency outside Boston University, the person who receives this information may disclose it again and the information may not be protected by federal or state privacy laws or regulations. I understand that I may choose whether or not to sign this form and that I do not need to sign this form in order to receive rehabilitation and recovery services from Boston University and/or the other person, facility or agency. However, without the ability to share or obtain information, Boston University and/or the other person/agency may not be able to provide effective rehabilitation and recovery services. Your Signature or Personal Representative s Signature Date Print Name of Signer 7

Boston University College of Health & Rehabilitation Sciences: Sargent College Center for Psychiatric Rehabilitation Stephanie Cummings, Administrative Manager Recovery Services Division 940 Commonwealth Avenue West Boston, Massachusetts 02215 T 617-353-1124 F 617-353-7700 stephc13@bu.edu cpr.bu.edu Please have your primary care physician or psychiatrist complete this form, and fax it to Stephanie Cummings at (617) 353-7700. Patient s Full MEDICAL AND PSYCHIATRIC FORM Physician/Psychiatrist Full Medical Facility/Clinic/Program: Date of Last Examination/Assessment: Diagnoses: Full DSM or ICD-10 Code(s): Initial date of diagnosis: Date of Last Clinical Contact: Psychiatric or Other Medication(s) Please List Any Restrictions/Recommendations: Physician/Psychiatrist s Signature: Date 8

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