Application

SEEDS OF HOPE, INC

ADMISSION APPLICATION AND ASSESSMENT FORM
Vivitrol Accepted. No Other MAT

Name Client first nameClient last name

DateDate

Address Client Address

Phone NumberClient phone

CityClient City

State Client State

Zip Code Client Zip

Date of Birth Client birthdate

Age Text field

Race Client race

Social Security Number SSN

Are you living with family Radio buttons

Are you living with friends?Radio buttons

Are you incarcerated? Radio buttons

If you are incarcerated, give a release date? Text field

Is your release date being determined upon acceptance into a program? Radio buttons

Are you coming from Detox? Text field Give name and number Text field
Are you coming from rehab? Text field Give name and number Text field
Are you coming from another transitional home? Text field
Give name and number Text field

If coming from treatment, when is your expected discharge date? Text field

Are you homeless Text field

Were you born a female? Text field

Have you ever been a resident at Seeds of Hope? Text field

LEGAL HISTORY

Have you engaged in illegal activities in order to obtain alcohol or drugs? Radio buttons
Have you been arrested for possession of illegal drugs? Radio buttons
Have you been arrested for DUI? Radio buttons
Have you been arrested for Public Intoxication? Radio buttons
Do you have any cases pending? Radio buttons
Is there a warrant out for your arrest? Radio buttons
Is there a possibility a warrant could be out for your arrest? Radio buttons

List charges for your incarceration and/or all pending chargesParagraph
Arrest Date Charge/County Comments Text field
List prior charges you have received which are not mentioned above. Text field
Date Charges Convictions/Outcome Text field
Are you currently on probation/parole? Text field
Name of probation/parole officer Phone Number Text field
Next court date and/or probation/parole appointment. Amount owed deemed by the court Text field

EMERGENCY CONTACT: List two

Name/Phone Number Text field
Address City State Text field
Relationship How often are you in contact with this person? Text field

Do you have insurance? Text field
Provider name of insurance Text field

Has your drinking or using drugs created problems between you and your family members? Text field

Have you lost friends because of your drinking and use of drugs?Text field

Has anyone ever told you that you have a problem with drinking or using drugs? Text field

Do most of the people you associate with drink or use drugs? Text field

Have you neglected your family because of your drinking and use of drugs? Text field

Are you currently married? Text field
Name of spouse Text field
Are you currently in a relationship? Text field
Does the person you are currently in a relationship with use any type drugs (alcohol is a drug) Text field

Your Sexual Preference Text field
Name of the person you are in a relationship with Text field
Do you have children? If so please list below:
Name Age Sex Lives with Paragraph
Is a county involved with the welfare of your children? Name of county: Text field
Case Manager Name Phone number Text field
What is your current visitation schedule? Text field

ALCOHOL/DRUG PROBLEMS
What is your drug of choice? Text field
Give last date of using any type of alcohol and/or drugs Text field
How old were you when you first used any type of alcohol and/or drug? Text field
How much do/did you use in a day? Text field
If you are not working, give a brief detail on how you obtain your drugs.Text field

Check all you have used in your lifetime
Alcohol Text field

BarbituratesText field
BenzodiazepinesText field
Xanax, Valium Text field

MarijuanaText field
Opiates (Vicodin, Heroin, Morphine, Oxycontin)Text field

Cocaine/Crack Text field

Date Rape DrugsText field
Amphetamine/Diet PillsText field
HallucinogensText field
PsychedelicsText field

InhalantsText field

MethamphetamineText field
List any drugs not mentioned above which you have used:Text field

Have you abused prescription drugs? Text field
Do you abuse more than one drug at a time? Text field
Do you drink or use drugs more than once a week? Text field
Have you tried to stop drinking or using drugs and were not able to do so? Text field
Have you had blackouts or flashbacks as a result of drinking or using drugs? Text field
Do you ever have feelings of guilt or shame about your drinking and using drugs? Text field

Do others complain about your involvement with drinking and using drugs? Text field
Is there a certain time of the day you crave a drink or to use drugs? Text field
Have you had financial difficulties as a result of drinking or using drugs? Text field
Has your ambition decreased since drinking or using drugs? Text field
Do you turn to inferior companions and environments when drinking or using drugs? Text field
Do you drink or use drugs alone? Text field
Do you drink and use it to enhance having a good time? Text field

Have you been involved in a treatment program related to substance use? Text field
List programs you have been involved within the past 10 years for:
Detox/Substance Abuse Treatment/Transitional Living
Date Facility/location Reason for leaving & length of stay Paragraph
Longest period of abstinence from all alcohol and/or drugs When?Text field
Give a brief detail on why you feel you were not able to remain substance free.Paragraph

MENTAL HEALTH
Have you been diagnosed with Schizophrenia? Text field
Have you been diagnosed with Manic Depressive? Text field
Have you been diagnosed Bi-Polar? Text field
Have you been diagnosed with PTSD? Text field
Have you been diagnosed with a Personality Disorder? Text field
List other diagnosis you have been given that are not mentioned Text field
Was your diagnosis before you started drinking or using drugs? Text field
Was your diagnosis after 1 year of being free from drinking or using drugs? Text field

Are you currently on any medication? Text field
LIST MEDICATION TYPE, MILLIGRAM, AND WHY

Paragraph
Do you have a history of taking any type of medication that you are not currently taking? Text field
LIST MEDICATION YOU NORMALLY TAKE WHICH YOU CURRENTLY ARE NOT TAKING & WHY. Text field
Have you ever been hospitalized for any mental illness? If yes list Text field
Date Facility/location Diagnosis and Treatment plan Text field
Have you ever attempted suicide? Text field
Do you have a history of self mutilating? Text field
Date you last attempted suicide Please give details of your last attempt Text field
Date you last self mutilated? Text field
Do you have any history of an eating disorder? Text field
ElaborateParagraph

MEDICAL HISTORY
Do you have any physical illness requiring regular medical care? Yes No
Elaborate Text field

Can you climb up and down stairs? Text field
Do you have a history with seizures? Text field
Give date you had your last seizure Text field
Do you have asthma? Text field
Do you have emphysema? Text field
Do you have Hepatitis? Text field
If so: What type? Text field
Do you have HIV/AIDS? Text field
Do you have high blood pressure? Text field
Do you have any type of blood disease? Text field
Is there a possibility you have a sexually transmitted disease? Text field
Are you pregnant or is there a chance you could be? Text field
What type of birth control, if any, are you using? Text field
When was your last menstrual period? Text field
Do you have a hearing problem? Text field
Do you have any unusual bruising or bleeding? Text field
Do you have any type of heart problems? Text field
Do you have an irregular heart beat? Text field
Have you ever been diagnosed with cancer? Text field
If so, what type of treatment did you receive? Text field
Do you have nausea, vomiting, diarrhea, or constipation? Text field
Do you take any type of over the counter medication? Text field
List over the counter medications Text field
Do you have diabetes? Text field
If so how is it controlled Text field

Are you currently in pain? Text field
If you are in pain, where is the pain? On a scale of 1-10 rate your pain 1 being very mild Text field
Do you take medication for pain? Text field
LIST MEDICATION YOU TAKE FOR PAIN. Text field
Have you had a physical within the past 12 months? Text field
Have you had a TB test within the past 12 months? Text field
Have you been seen by a doctor in the past 12 months? Text field
If you have been seen by doctors, why? Text field

EMPLOYMENT HISTORY
Are you currently employed? Text field
Days and time you are scheduled to work Text field
Present Employer information Text field
Name Phone Number Text field
Address Text field
City State Zip Code Text field
Supervisor Phone Number Text field
Pay Rate Net income Pay date Text field
Weekly Bi Weekly Monthly Text field
If you are not working when is the last time you held a job Text field
Are you currently on disability? Text field
Have you applied for disability Text field
Are you able to be employed 32 hours a week? Text field
If you are not able to be employed 32 hours a week, please explain. Text field

Have you ever been in trouble at work because of your use of alcohol and/or drugs? Text field
Have you lost a job because of alcohol and/or drug use? Text field
Are you trained in a specific field Text field
If you are trained in a specific field state the field:Text field
What is the highest level education you completed? Text field

Do you have a state ID? Text field
Do you have a social security card? Text field
Do you have a birth certificate? Text field
Do you have a driver’s license? Text field
Do you have a vehicle? Text field
Is your vehicle properly registered? Text field
Is your vehicle insured? Text field

FINANCIAL
Do you receive food stamps? Text field
If yes state how much:Text field
Do you have a checking account or savings account? Text field
If yes give name of bank and dollar amount in account:Text field
Do you receive child support? Text field
If yes how much: Text field
If yes, give the name of the bank and submit your last bank
statement? Text field
List all debtors (include court, and probation fees, child support/care) amount owed, payment arrangements:Text field
Name Total owed Arrangements made/How often and amount: Text field

RECOVERY
Have you ever attended a 12 step meeting (AA/CA/NA)? Text field
Do you have a sponsor within a 12 step program (AA/CA/NA)? Text field
If you have a sponsor please give name and number Text field
How do you feel Seeds of Hope can help you?Paragraph
What do you feel will be your biggest problem(s) maintaining abstinence from alcohol and drugsParagraph
I acknowledge that this information is true and, if I have knowingly falsified anything, I could
automatically become ineligible for acceptance and/or admission into Seeds of Hope.
Client first nameClient last nameDate
Applicant’s Signature

What's the best way to reach you about your application? If you're currently in treatment, include your case manager's email. Text field