Admission Application

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Admission Application

Name(Required)

First Middle/Maiden Last

Date of Interview(Required)

Date Admitted(Required)

Referred By(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

County(Required)

Zip Code of Last Permanent Address(Required)

Social History

Age

Race

Date of Birth

Mother's Name (Married & Maiden)

First Middle/Maiden Last

Father's Name

First Middle Last

Prior Admission to Hope Haven?(Required)

Yes

Date Last Discharged(Required)

Last School Grade Completed(Required)

Did you like school?(Required)

Yes

Why or Why Not?(Required)

Are you presently enrolled in school?(Required)

Yes

If so, where?(Required)

Are you currently on State or Federal probation?(Required)

Yes

For what charges?(Required)

PO Name(Required)

First Last

PO Phone Number(Required)

Do we have your criminal background report?(Required)

Yes

Employment History

Types and Skills(Required)

Occupation(Required)

Last Employer(Required)

Is this your current employer?(Required)

Yes

VR involvement?(Required)

Yes

Did you serve in the military?(Required)

Yes

Branches/Dates(Required)

Did you like your stay in the military?(Required)

Yes

Why or Why Not?(Required)

What was your discharge status?(Required)

Discharge Date

Income Information

Any source or type of income?(Required)

Yes

Amount of Income(Required)

If yes, what type of income?(Required)

Pension/Retirement

SSI/SSDI

TANF

Unemployment

VA Benefits

Other

Are you in the process of filing disability?(Required)

Yes

If so, what is your status?(Required)

Awaiting Hearing

Denied

Income Pending

Do you receive Medicaid?(Required)

Yes

Medicaid Number(Required)

Do you receive Medicare?(Required)

Yes

Medicare Number(Required)

History of Addiction/Alcoholism

Do you have a history of the following (select all that apply)

Blackouts

DTs

Epilepsy

Neuritis

Hallucinations

Date of Last Drink/Use(Required)

Age of First Drink/Use(Required)

At what age did alcohol/drugs become a problem?(Required)

Alcohol/drug related arrests?(Required)

Yes

If yes, please explain(Required)

Other arrests?(Required)

Yes

If yes, please explain(Required)

Previous Treatments (List where and when)(Required)

Longest Clean Time(Required)

Sponsor?(Required)

Yes

Psychological History

Have you ever been a patient in a mental hospital?(Required)

Yes

If yes, explain with date(s)(Required)

Have you ever had a mental health assessment/evaluation?(Required)

Yes

If yes, explain with date(s)(Required)

Have you had any of the following in the last two months?

Financial Burdens

Lack of Sexual Desire

Irritability

Family Problems

Weight Loss

Staring Spells

Problems with Job

Employment

Separation/Divorce

Has there been abuse in your marriage or intimate relationships?(Required)

Yes

How well do/did you get along with your significant other/spouse?(Required)

Number

How well do/did you get along with your child(ren)?(Required)

Living arrangements prior to treatment?(Required)

Number in Household

Do you ever feel afraid of your partner?(Required)

Yes

In what ways?(Required)

Has there ever been any violence in your intimate relationships? (Example: pushing, pulling, slapping, punching or kicking)(Required)

Yes

How long ago did the most recent violence occur?(Required)

Has there ever been fighting in your intimate relationships that led to damage or destruction of personal belongings, property, or pets?(Required)

Yes

Have there ever been threats to use weapons such as a gun, knives by you or your partner?(Required)

Yes

Have you ever had a partner force you to have sex against your will?(Required)

Yes

Has physical abuse ever occurred while you were high?(Required)

Yes

Has physical abuse ever occurred while your partner was high?(Required)

Yes

Have you ever gotten high to cope with the violence in your relationships?(Required)

Yes

Have the police ever been called to your home due to fighting?(Required)

Yes

Medical History

Family Doctor

First Last

Address

Street Address Address Line 2 City State ZIP Code

Date of last physical examination?(Required)

Date of last TB Test:(Required)

Result(Required)

Positive

Negative

Do you have a history of

Diabetes

Epilepsy

High Blood Pressure

Cancer

Nervous/Mental Disorder

Other

If other, explain(Required)

What over the counter medications have you taken in the last 6 months?(Required)

What medications are you allergic or sensitive to?(Required)

Are you currently on medication(s)?(Required)

Yes

If yes, name(s) of medication(Required)

Prescribed by(Required)

First Last

Do you presently have a disability that is covered under the Americans with Disabilities Act (ADA) that will require special accommodations or specific needs?(Required)

Yes

If yes, then what is that disability and what specific accommodations or specific need will need to be made?(Required)

Level of Functioning(Required)

Specific Needs(Required)

Females Only

If you are not female, please skip to the next section.

Are you pregnant now?(Required)

Yes

# of times pregnant(Required)

Last menstrual period date(Required)

Flow

Light

Heavy

Abnormal Discharge

Last pap smear date

Results

Breast Exam

Pain

Lump

Discharge

Emergency Contact Information

Name(Required)

First Last

Phone(Required)

Relationship(Required)

Complete Address(Required)

Street Address Address Line 2 City State ZIP Code

Consent

Please read and agree to the following

As a resident of Hope Haven, I understand and accept my written responsibilities. In consideration of your admitting me as a resident to Hope Haven, I, for myself, my heirs, assigns or personal representatives, do hereby release you and your staff from any liability for any personal injury or property damage that I may sustain at any time at Hope haven, or on its premises or while I am a passenger in any vehicle, and further agree to hold Hope Haven, Inc. free and harmless from any and all liability in connection therewith:

I agree

Resident Signature(Required)

Date(Required)