Prospective Resident Form | Hope Haven, Inc

MEN - WOMEN - FAMILIES - PBH - LEVEL 3

* required - if you do not know the answer please put unsure or does not apply

Full Name*

Last 4 digits of SSN*

Referral Date*

Referral Source Name*

Referral Agency/Facility*

Phone*

Date Available for admission*

Current Living Address*

Street Address Address Line 2 City State ZIP Code

Mecklenburg County Resident*

Yes
No

Homeless*

Yes
No

Date of Birth*

Race*

Hispanic*

Yes
No

Gender*

Male
Female

Marital Status*

Married
Single
Divorced
Widowed

Diagnosis*

Sobriety Date*

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?*

Yes
No

What Agency/Support Services?*

Any Court charges/cases pending?*

Yes
No

Explain Court charges/cases pending*

Probation/Parole*

Yes
No

Explain Probation/Parole

Domestic Violence/Rape/Child Abuse Record?*

Yes
No

Explain 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*

Men
Women
Families
Serenity House