Admission Application

General Information
* Name
* Gender
* Date of Birth
* Social Security Number
Client Reference Number
* Racial Background
* Marital Status
* Permanent Address
* Emergency Contact Name
* Emergency Contact Address
* Emergency Contact Phone Number
What is your relationship to this emergency contact?
Secondary Emergency Contact Name
Do you have any children?
How did you hear about us?
* Emergency Contact Email Address
Is anyone helping you financially to pay for any of your daily needs?
Describe who is helping you, how often and the amount of financial help recieved
Cost of current monthly rent or house payment
Cost of current monthly utilities (electric, phone, gas, water)
Cost of current other monthly transportation
Cost of current monthly food expenses
Cost of monthly medical expenses
Enter the item and the cost of any other expenses you want to have considered
Secondary Emergency Contact Address
Secondary Emergency Contact Phone Number
What is your relationship to this secondary emergency contact?
* Client Cell Phone Number
If you found us via a Treatment Center, which one referred you?
Billing Information
* Address
* City
* State
* Zip
* E-mail Address
* Primary Telephone Number
Portal Access
* Username
* Temporary Password
Recovery History
When was the last time you used drugs or alcohol?
Date of Sobriety
What are your drug(s) of choice?
What do you hope to get out of transitional living?
Do you have severe apprehensions about being here?
Have you lived in recovery housing before?
Have you been in recovery before?
What was your longest period of sustained abstinence?
What are your goals in recovery?
What are your short term goals?
Do you have any long term goals? If so, please specify:
What do you see as the biggest barriers to your continued recovery?
Are you currently enrolled in any PHP treatment services?
Are you currently enrolled in any IOP treatment services?
Criminal Justice History
Have you ever been arrested?
Have you been convicted of a crime?
Have you ever been required to register in the National Sex Offender Database? Lookup
Are you currently required to pay child support?
Have you ever been charged with: abuse or neglect of a child, disabled person or senior; abuse or harm to an animal; arson; forgery; identity theft?
Do you have any existing or outstanding court fees?
Medical History
Do you have any physical health conditions?
Do you have any mental health disorders?
Have you ever attempted suicide?
Have you ever tested positive for HIV?
Have you ever tested positive for Hepatitis C?
Have you ever tested positive for Tuberculosis?
Employment Readiness
Are you currently recieving Social Security Benefits?
Are you currently recieving Disability Benefits?
Are you currently employed?
Do you own your own vehicle?
Highest Level of Education
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