Application for Residential Treatment Application for Treatment X/TwitterThis field is for validation purposes and should be left unchanged.Date Initial InformationName(Required) First Last Age(Required)Date of Birth(Required) Month Day Year Address(Required) Street Address City StageAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Email(Required) Race/Ethnicity(Required) White Black American Indian Asian Hispanic Non-Hispanic Other Have you lived with or spent more than 8 hours at a time with someone you knew was sick from TB?(Required) Yes No Drug of Choice(Required)Date of last use(Required) Month Day Year Name of Drug/Alcohol(Required)Amount(Required)History of Domestic Violence:(Required) Yes No If Yes, When and Where?(Required)History of any sexual-related crimes:(Required) Yes No If Yes, What, When, & Where?(Required)Mental Health Diagnoses:(Required) Yes No If Yes, When & Where?(Required)Previous MH Treatment:(Required) Yes No If Yes, When & Where?(Required)MH Treatment Completed:(Required) Yes No Number of Days in Txt:(Required)If treatment not completed, why?(Required)Current MedicationsName & mgPurposeFor How LongDose30-day supplyName & mgPurposeFor How LongDose30-day supplyName & mgPurposeFor How LongDose30-day supplyAdditional Current MedicationsIf you have more current medications, please list in the textbox below.Previous SUD Treatment:(Required) Yes No If Yes, When and Where?(Required)SUD Treatment Completed:(Required) Yes No Number of Days in Txt:(Required)If treatment not completed, why?(Required)Physical Condition(Required)Last Medical Visit/Checkup(Required) Month Day Year Medical Issues:(Required)Do you need wheelchair accessibility?(Required) Yes No History of Self Harm?(Required) Yes No How many close friends does client have? *(Required)Who do you spend most of your time with?(Required)Please select all that apply. Friends Family Alone Legal InformationAny pending legal problems?(Required) Yes No If Yes, Describe:(Required)Participating in a Specialty Program/Court?(Required) Yes No If Yes, Name of the Program/Court:(Required)Example: Tulsa County Drug CourtOn Probation/Parole?(Required) Yes No Court ordered to treatment?(Required) Yes No If Yes, Reason behind Court Order:(Required)Referral/Financial InformationWho referred you to House of Hope?(Required)Reason for seeking treatment(Required)Own Home(Required) Yes No Marital Status(Required)Number of Dependent Children(Required)Child Support Order?(Required) Yes No N/A Current on Support? Yes No N/A Currently Employed?(Required) Yes No If Yes, Name of Employer and length of employment:(Required)If No, how long unemployed?(Required)Total Household Income the last 12 months:(Required)Total number living in household:(Required)How long at present address?(Required)Veteran?(Required) Yes No Private Health Insurance(Required) Yes No
