Admission Application

General Information

Social Security Number (Optional)
* Name
* Gender
* Date of Birth

Personal Information

* Address
* City
* Country
* State/Province
* Zip
* E-mail Address
* Primary Telephone Number
* Preferred communication method

Admission - Demographic

Marital Status:
Do you have Children?
If yes, who is caring for them?
Level of Education:
Are you a Veteran?
Are you pregnant?
Who referred you to us?

Admission - Criminal Justice

Pending Charges or Legal Issues:
If yes, please explain:
Upcoming Court Dates:
If yes, please explain:
Are you currently in a Prison or Jail?
If yes, where?
Are you Court Ordered to a Seed Sower residence?
County:
Judge:
Obtained Order:
Do you report to a Probation Officer?
If yes, name & phone:
Misdemeanor Conviction?
If yes, please list:
Felony Conviction in the past 3 years?
If yes, please list:

Admission - Additional Information

Do you currently own or rent?
Monthly Payment or Rent: 
How long at this address?
Where have you lived for the past 6 months?

Admission - Recovery and Substance Use History

Have you been a resident at a Seed Sower residence before?
If yes, when?
Have you sought services for a substance use disorder in the past?
If yes, please list dates and providers: 
What was your drug of choice?
When was your last incidence of use?

Admission - Medical and Mental Health

Do you have Medical Insurance?
If yes, please list:
Do you have any food or other allergies?
If yes, please list:
Are you allergic to any medications?
If yes, please list:
Do you have any of the following medical conditions? (select all that apply)
If yes to any of the above, are you currently taking any medications for treatment?
Are you able to stand for up to 8 hours and lift 25 lbs safely?
Do you have a primary care physician?
If yes, please list name and phone number
Have you had a TB Skin Test?
If yes, please list last test date and result (positive or negative):
Please list all medications you are currently taking:
Do you have any diagnosed mental health conditions or symptoms?
If yes, please list:
Are you under the care of a mental health provider?
If yes, please list name and phone number:
Have you attempted suicide in the past?
If yes, how many times?
Did you have a specific plan?
Were you under the influence at that time?

Admission - Emergency Contact Information

Emergency Contact:
Relation:
If "other", please specify:
Phone Number:
City, State:
Address: