Healing Hearts Lodge

6002 N 19th Street

Bismarck, ND 58503

(701) 712- 3260

 

Applicant Name:Client first name Client last name

Today's Date:Text field

Phone Number:Client phone

Email Address:Client email

Please ensure you are listing a number or email address that we can reach you at.

D.O.B Client birthdate

MHA enrollment number: Text field

Desired entry date: Text field

Planned exit date (9 months recommended): Client estimated length of stay

(declining a commitment to stay 9 months may result in denial)

Current Address: Client Address

Client CityClient StateClient Zip

Emergency Contact/Relative Name:Family Members Phone Number: Text field

How long have you been using alcohol and/or drugs? Paragraph

How do you identify youself: Alcoholic:Text field Addict:Text field Alcohol&Drug Addicted:Text field

Do you have a history of seizures? Yes:Text field No:Text field

 

List all mind-altering substances (drugs,alcohol, etc.) that you have used in the last three years: Text field

What was the last substance used, and when? Text field

Probation or parole officer: Text field Number:Text field

Probation or parole location (County, State, Federal, Tribal):Text field

Attorney:Text field Phone number:Text field

Employment: Text field Phone Number: Text field

AA/NA Sponsor:Text field Phone Number:Text field

Counselor: Text field Phone Number:Text field

Primary Care Provider:Text field Phone Number:Text field

Marital Status: Single:Text field Married:Text field Seperated:Text field Divorced:Text field

Prior Treatment Facilities or centers and locations: TreatmentCenterHistorySoberLivingHistory

Do you have a criminal record? If so, please list any charges you have, any charges against children, open cases and any active warrants you are aware of. Text field

Do you have any mental health issues or diagnosis? Yes:Text field No:Text field

If yes, what are they and are you currently taking any medications for these? Text field

Do you have nay physical health/medical concerns or disabilities? Yes:Text field No:Text field

If so, please list them: Text field

Have you been prescribed any medications within the last six months? Yes:Text field No:Text field

List ALL the medications presicribes in the past six months that you are currently taking, and the last date taken:

Medication: Medication Last Taken: Date

Are you required to register as a sex offender? Yes: Text field No:Text field

Are there any restraining orders against you or by you? Yes: Text field No:Text field

If yes, who: Paragraph

Relationship to you: Text field

 

 Are you associated with anyone in MHA Sober Living or the Healing Hearts Lodge? Yes: Text field No: Text field

If yes who?

Name: Text field Relationship: Text field

Have you ever lived in a home shared with other people? Yes: Text field No: Text field

If yes, please explain: Paragraph

Please list ages and gender of any children you plan to bring to the program with you and when: Paragraph

Are you pregnant or believe you may be pregnant? Yes: Text field No: Text field

If yes, what is your due date? Date

Do you currently have any open CPS/CFS cases? Yes: Text field No: Text field

If yes, where and what county or court? Text field

Case worker name: Text field Phone number: Text field

Do you own a vehicle or plan to bring one to HHL? Yes: Text field No:Text field

If so, a valid driver's license, vehicle registration documentation, in applicant's name, as well as auto insurance documentation in applicant's name will need to be provided before vehicle can be driven. 

Can you provide all three of these documents? Yes: Text field No: Text field

Please briefly explain why you are intersted in Healing Hearts.

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