Men, Women & Women w/ Children (recovery homes, stphh housing, recuprative care, housing navigation)

BELOVED HOUSING LLC ❤

 

 

ATTENDEE APPLICATION 

ALL AREAS MUST BE FILLED OUT 

Date: Date	Referred by: Text field
Name: Client first name Client last name	Date of Birth: Client birthdate
	Mobile Phone: Client phone
Alternate Phone: Text field	Email Address: Client email
Emergency Contact: Text field	Emergency Contact Phone #: Text field

Program your interested in :Checkboxes

 

 Are you homeless or at risk of homelessness? Text field

 

Type of insurance : Text field

 

Do you have medi-cal ? Checkboxes

 

Do you have IEHP: Checkboxes

 

Are you on Parole/Probation? : Text field

 

1. Have you previously resided in a shelter, Sober Living or transitional Housing? Checkboxes

1A. Have you been to Rehab? Detox/ Residental SUD Treatment, outpatient IOP? Checkboxes if so when and where? Text field

1B. Have you been in hospital in the last 30 days?Checkboxes 

 

2. If you struggle with addiction, Describe your addiction, drug of choice and length of time you have struggled with your addiction (if not put n/a):

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3. Briefly describe your understanding of a 12 step Recovery Program?

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4. List any Parole and/or Probation (include dates and description or put n/a):

 

 

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5. Describe any physical and/or mental health diagnosis:

 

 

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6. Describe any physical disabilities: 

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8. Detail any hospitalizations:

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9. Are you currently experiencing thoughts of harming youself or others? :

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Print Name:  Text field

Date:  Date

Signature of person completing form:

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Witnessed by (if someone is assisting you): Text field

Signature

Date:  Date

 

Additional Comments:

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All of our programs require sober enviornments. When was the last time you used/drank or relapsed?  

 

Please describe.

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• Are you interested in our Christian Faith based program?   Checkboxes

 

• Do you participate in 12 step meetings (celebrate recovery , NA, AA, CA ?)Text field

 

 

• Do you currently have income and what is the source (cash aid, ssi, ssdi, employment, unemployment etc)?

 

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