A.) HENSLEY HOUSE NEW MEMBER APPLICATION \ INTAKE FORM

 Welcome to the Hensley House Application \ Intake Wizard 🪄 

Thank you for considering Hensley House Sober Living Home!
So that we can help provide you with the best possible fit for where you are in the recovery process, please complete the New Resident Application Form below. 

The collected registration data is kept strictly confidential. 

Click next to begin!

General

Tell us about yourself
What is your first name? *(Please put your first and last name as they appear on your drivers license)
Client first name
What is your last name?
Client last name
When is your birthdate?
Client birthdate
What is your gender?
Client gender
What is your marital status?
Client marital status
Are you a veteran?
Client veteran

Contact Information

How can we reach you?
What is your email address?
Client email
At what phone number can we best reach you at?
Client phone
Street Address:
Client Address
City:
Client City
State:
Client State
Zipcode:
Client Zip

Emergency Contacts

Give us a few people that we can reach out to in case of an emergency. (it is a requirement to list at least one emergency contact)
 
Contact 
 

For Those Currently In Treatment

If you are currently in a treatment center and don't have regular access to your phone, list a contact person at the treatment center or a friend or family member we can call to discuss your sober living options. 

Contact

Medical History

Tell us about your medical history.
What is your sobriety date?
Recovery history 1 relapse date
What is your substance(s) of choice? Add multiple by clicking in the box and selecting different options
Client substances of choice
Have you been clinically diagnosed with anything? Add multiple by clicking in the box and selecting different options
Client diagnosis
Do you have any health problems? Add multiple by clicking in the box and selecting different options
Client health problems
Have you ever been hospitalized or institutionalized for attempted suicide or having suicidal ideations? 
Radio buttons
Are you an insulin dependent diabetic?
Radio buttons
Have you ever been diagnosed with COPD? (Chronic Obstructive Pulmonary Disease)
Radio buttons
Are you currently taking any MAT (Medically Assisted Treatment) medications? (eg. Suboxone, Sublocade, Methadone)
Radio buttons
Are you currently taking any "scheduled" medications? (ie. are you prescribed any narcotic medications such as Adderal, Xanax, Alprazolam, Anabolic Steroids, Ambien, etc.)
Radio buttons
If you checked "yes", please write the name of the medication. 
Text field
 

Legal

Have you ever been convicted of any sexual related offenses or child abuse related offenses?
Radio buttons

Medications

List the medications you are currently prescribed. If you don't know or don't have all the details readily avaialble (eg. dosage, quantity, category, pill count etc.), just list the names of the different medications you are currently taking. 
Medication

 

Treatment Center/s

Tell us about the most recent treatment center you've been admitted into. If you don't have all the details of the most recent treatment center you've been to, please list the name of the treatment center, what city and state it was in, your best guess of when it started and ended, the type of treatment center, and the reason for discharge. Additionally, if you are currently in a treatment center, please list the details of the current facility you are in. 
TreatmentCenterHistory

 

Client Referral Source

 

Who referred you to us?
*if you see the name of your referral source in the drop down list, click on that name. Otherwise, please type in the name of the referral source in the box. 
Client Referred By

 

 

Occupancy

What date would you like to move into Hensley House?
Date
The minimum length of stay at Hensley House is 3 months (90 days). Are you willing to commit to staying at Hensley House for a minimum of 90 days?
Radio buttons
Will you be able to provide a clean urine sample when you arrive?
Radio buttons

Last one

Are there any unique circumstances or anything you would like us to know about your situation before you submit this form?

Paragraph