Client facility
PERSONAL INFORMATION
Name
Client first name
Client last name
DOB
Client birthdate
Age
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Sex
Male or Female
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Spouse Name
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Marital Status [Single, Divorced, Married, Widowed, or Domestic Partnership]
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Emergency Contact [Name, Relationship, and Phone Number]
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Emergency Contact Address
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DL or ID Number
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Height
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Weight
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Social Security Number
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Address
Client Address
Are you currently experiencing Homelessness? Yes or No
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If YES, How long have you been homeless?
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Are you currently experiencing active addiction? Yes or No
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If YES, How long have you been in active addiction?
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Phone
Phone field
Religion
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Race/Ethnicity
Client race
Are you currently receiving any type of income? If yes, please explain.
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Have you ever been in the military? If so, what was the nature of your discharge (honorable, OTH, dishonorable, bad conduct,e tc.)? Please explain.
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EDUCATION
Last year of school completed
EducationHistory
Can you read and write? [Yes( Read and Write), Read only, or No]
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Do you speak english?
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LEGAL HISTORY
Have you ever been arrested? Yes or No
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If yes, how many times?
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Felon? Yes or No
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If yes, give details and the name you were arrested under.
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Have you served time in jail or the penitentiary? If yes, please explain the conviction and how long you served.
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Legal Status (Probation, Parole, or Court Ordered?)
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Legal Contact Info
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Do you have legal charges pending? If yes, please explain and include the location and description of the charges.
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Do you think you may have outstanding warrants? If yes, please explain.
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Do you have any other pending legal matters that would require your attention in the next 90 days? If yes, please explain.
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MEDICAL HISTORY
Date of last physical exam. If you dont know the exact date, give the year.
Date
Medical Conditions
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Have you ever been diagnosed with a mental health condition? If YES, pleast list the diagnosis and dates of any admissions to a mental health institution.
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Are you currently pregnant? Yes or No
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Have you been pregnant before? Yes or No
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Number of Children
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Custody Status [in custody, CPS case, kinship care, no custody, partial custody, supervised visitation, foster care]
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Do you wear glasses? Yes or No
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Do you wear contacts? Yes or No
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Do you have any allergies to medications or foods?
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Do you have any chronic medical conditions not listed above that require regular visits to the doctor? If yes, please explain.
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Medications
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What is your sexual orientation? (We do not use this information in consideration for the program)
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Have you ever used illegal drugs? Yes or No
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If yes, how old were you when you tried drugs for the first time?
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Have you ever sold/distributed illegal drugs? Yes or No
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Do you think you have a problem with drugs? Why or why not?
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Since you started using, what is the longest period of time youve been sober?
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GOALS
What goals do you have while in this program?
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What do you want to happen in your life while you are in this program?
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How did you hear about us? (friend, family member, church member/pastor, staff, google, social media, flyer/brochure, other)
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DRUG HISTORY (If Applicable)
Drug Use History
Client substances of choice
Please list the first time you used each of the substances you marked above.
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Please list the last time you used each of the substances marked above
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Please list how often you used each of the substances marked above (rarely, occasionally, monthly, weekly, daily)
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Please list how much of the substance you used per day/week/month.
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INITIAL 30 DAYS
Are you willing to give up your phone for 30 days?
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If you have a job, does your boss know that you will be unavailable to work for 30 days?
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Are you afraid of dogs?
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There is a dog who lives in this home. Are you ok with that?
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What are the circumstances surrounding the situation that caused you to need our program? Please give as many details as possible.
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Are you applying for Emergency Placement Program or the 90 Day Residential Program?
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If you are applying for Emergency Placement Program, what is the name of the facility you are waiting to get in and what date are you going there?
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