MEN - WOMEN - FAMILIES - PBH - LEVEL 3* required - if you do not know the answer please put unsure or does not applyFull Name*Last 4 digits of SSN*Referral Date* Date Format: MM slash DD slash YYYY Referral Source Name*Referral Agency/Facility*Phone*Date Available for admission* Date Format: MM slash DD slash YYYY Current Living Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mecklenburg County Resident*YesNoHomeless*YesNoDate of Birth* Date Format: MM slash DD slash YYYY Race*Hispanic*YesNoGender*MaleFemaleMarital Status*MarriedSingleDivorcedWidowedDiagnosis*AlcoholCocaineCannabisOpiatesSobriety Date* Date Format: MM slash DD slash YYYY Secondary Diagnosis*Previous Treatment within last calendar year(Date & location)Medication* Physical Disabilities* Are you receiving Receiving Food Stamps WIC TANF SSI SSDI VA Any Agency/Support Services Involvement?*YesNoWhat Agency/Support Services?*Any Court charges/cases pending?*YesNoExplain Court charges/cases pending*Probation/Parole*YesNoExplain Probation/ParoleDomestic Violence/Rape/Child Abuse Record?*YesNoExplain Domestic Violence/Rape/Child Abuse You will need the following before admission to requested program at Hope Haven: Picture Identification Social Security Card Criminal Background Check Proof of Physical Examination Prescriber Letter for Medication Proof of TB Test Verification of Homelessness Letter (if applicable) Comprehensive Clinical Assessment Notes(Including your contact information if you are not being referred by a facility.)Program requested*MenWomenFamiliesSerenity House