Jeremiah House Application 

General

First Name: Client first name 

Middle Name: Client middle name 

Last Name: Client last name

Address: Client Address

City: Client City State: Client State Zip: Client Zip

Email: Client email Phone Number: Client phone

Gender: Client gender Birthdate: Client birthdate

School: Client school

Marital status: Client marital status.     

Any childrenText field

If Yes, is there any child support paymentsText field

Race: Client race

Veteran: Client veteran status

 

Desired Move in Date: Date

What is your sober date:

Client sobriety date

 

 

Medical History

Diagnosis: Client diagnosis Health problems: Client health problems

 

Substance of Choice: Client substances of choice

Lenght of useText field   Age you started usingText field

Kinds of meetings attended: Client kinds of meetings attended

Allergies: Client allergies Relapse Date: Client relapse date

Current medications

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Any Mental Health diagnoses?Text field

If Yes, please list and explain

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 Any suicide attempts Text field

If so please explan

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Any current suicidal thoughts?Text field

 

 Why is now the time? How serious are you about this?

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 Are you willing to commit to a 12 month recovery programText field

 

Referral source:

 Client Referred By

Licence number Text field SS#Text field

Food Stamp Number:Text field Pin #Text field

Criminal Record

Any viloent charges?Text field

If yes, please give a brief description

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Any other criminal charges?Text field 

Please explain

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Any sexual offence chargesText field

 

Insurance Information:

Health Insurance: 

Checkboxes

Health Insurance Policy

Provider: Client insurance provider Insurance Plan: Client insurance plan

Group ID: Client insurance group ID Policy#: Client insurance policy #

Address:(Street) (City) (State) (Zip) Text field

 

Are you receiving welfare, unemployment compensation, disability payments, workman’s comp, alimony, VA benefits, or other income?

Checkboxes

Explain: Paragraph

 

How would you rate your personal health?

Checkboxes

 

HAVE YOU EXPERIENCED OR DO YOU PRESENTLY HAVE A PHYSICAL AILMENT, INJURY, HANDICAP OR MEDICAL PROBLEM THAT WOULD PREVENT YOU FROM PERFORMING MANUAL LABOR WHILE ENROLLED AT 'INSERT FACILITY/PROGRAM NAME' ?

Checkboxes

IF YES, PLEASE EXPLAIN:

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Intake Coordinator notes:

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