Application for Residential Treatment Application for Treatment This field is hidden when viewing the formDate 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 & 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 CAPTCHA
