Application for Residential Treatment Application for Treatment HiddenDate MM slash DD slash YYYY 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 & mg Purpose For How Long Dose 30-day supply Name & mg Purpose For How Long Dose 30-day supply Name & mg Purpose For How Long Dose 30-day supply Additional 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 Court On 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 CAPTCHA
