Application for Residential Treatment Application for Treatment If you are human, leave this field blank.Page BreakInitial InformationName *Age *Date of Birth *Address *CountryUnited States (US)United Kingdom (UK)CanadaAustralia---AfghanistanÅland IslandsAlbaniaAlgeriaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAmerican SamoaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelauBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraÇaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqRepublic of IrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Martin (Dutch part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSan MarinoSão Tomé and PríncipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaWestern SamoaYemenZambiaZimbabweCityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces (AA)Armed Forces (AE)Armed Forces (AP)American SamoaGuamNorthern Mariana IslandsPuerto RicoUS Minor Outlying IslandsUS Virgin IslandsZip codePhone *Email *Race/Ethnicity *WhiteBlackAmerican IndianAsianHispanicNon-HispanicOtherHave you lived with or spent more than 8 hours at a time with someone you knew was sick from TB? *YesNoDrug of Choice *Date of Last Use *Name of Drug/Alcohol *Amount *History of Domestic Violence: *YesNoIf Yes, When and Where? *History of any sexual-related crimes: *YesNoIf Yes, What, When, & Where? *Mental Health Diagnoses: *YesNoIf Yes, When & Where? *Previous MH Treatment: *YesNoIf Yes, When & Where? *MH Treatment Completed: *YesNoNumber of Days in Txt: *If treatment not completed, why? *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: *YesNoIf Yes, When and Where? *SUD Treatment Completed: *YesNoNumber of Days in Txt: *If treatment not completed, why? *Physical Condition *Last Medical Visit/Checkup *Medical Issues: *Do you need wheelchair accessibility? *YesNoHistory of Self Harm? *YesNoHow many close friends does client have? *Who do you spend most of your time with? *FamilyFriendsAlone Page Break *Legal InformationAny pending legal problems? *YesNoIf Yes, Describe: *Participating in a Specialty Program/Court: *YesNoIf Yes, Name of the Program/Court: *example: Tulsa County Drug CourtOn Probation/Parole: *YesNoCourt ordered to treatment? *YesNoIf Yes, Reason behind Court Order: * Referral/Financial InformationWho referred you to House of Hope? *Reason for seeking treatment *Own Home: *YesNoMarital Status *# of Dependent Children *Child Support Order:YesNoN/ACurrent on Support: *YesNoN/ACurrently Employed: *YesNoIf Yes, Name of Employer and length of employment: *If No, how long unemployed: *Total Household Income the last 12 months: *Total number living in household: *How long at present address: *Veteran *YesNoPrivate Health Insurance *YesNo Submit
