01 - INITIAL APPLICATION - Intake Form

Freedom House for Women, Inc. - Application / Intake Form

This is an application for consideration to participate in the Freedom House for Women, Inc. Sober Living Program, a short-term, supportive recovery environment.  

Please read entire application carefully and answer each question completely, to be best of your knowledge.  If a question does not apply to you, you must answer "N/A" (not applicable).

Incomplete applications will not be considered.

RELEASE OF INFORMATION 

This form authorizes the release, exchange, and discussion of all my protected health information (PHI) between myself, my Residential and Outpatient Treatment Programs and Freedom House for Women, Inc. and it's staff for the purposes of review of this application, for coordinating housing and supportive services, for monitoring compliance with house rules and sobriety requirements, and responding to relapse and medical emergencies with my treatment providers listed below.
 
Some examples of PHI to be shared are listed, but not limited to: Verification of sobriety status and drug/alcohol testing results, Medical or mental health information relevant to housing stability and safety, Emergency contact information, Program participation and progress updates, Incident reports and behavioral observations
 
This authorization allows release of information to Freedom House for Women, Inc. and it's staff and the 3rd-party Treatment Programs listed below:
 
Residential Treatment Program (must include): Text field     Dates attended Date

Outpatient Treatment Program: (must include): Text field    Dates attended Date

I understand that my PHI will be protected in compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This authorization will remain valid for the duration of my residency at Freedom House for Women, Inc. and will expire one year after my discharge date.
SignatureSignature

TELL US ABOUT YOURSELF:
What is your first name?
Client first name
What is your last name?
Client last name
When is your birthdate?
Client birthdate
What is your biological sex, assigned at birth?
Text field
What is your marital status?
Client marital status
What is your email address?
Client email
At what phone number can we best reach you at?
Client phone
Home / Street Address:*
Client Address
City:*
Client City
State:*
Client State
Zipcode:*
Client Zip
 
MUST LIST NAME AND PHONE # OF 3 EMERGENCY CONTACTS: your sponsor, a family member, closest friend. 
Contact Friend/Name 
Family MembersFamily Member
Client sponsor
INSURANCE:   Enter your insurance provider and policy #. 
Insurance Insurance
MEDICAL INFORMATION:
What is your sobriety or last relapse date?
RecoveryHistory
What is your substance(s) of choice? List all substances.
Client substances of choice
Are you currently prescribed any CONTROLLED medications?
Radio buttons
If yes, what medications? List all.
Medication
Have you been diagnosed with Schizophrenia, OCD, Anorexia, Dementia, Seizures, Disassociative Identity Disorder, Borderline Personality Disorder, Bi-Polar? If yes, which ones?
Client diagnosis
Do you have a history of Self-Harm to yourself or others? Suicide Ideation, Plan or Attempt? Explain in detail.
Text field
Do you have a history of aggressive or combative verbal or physical behavior? If yes, explain in detail.
Text field
Do you have any health problems or require medical or non-medical accomodations?
Client health problems
What kind of meetings do you attend?
Client kinds of meetings attended
Do you have any allergies?  If yes, please explain.
Client allergies
MEDICATIONS:  LIST ALL:
Are you on any medications?* Radio buttons
Medication 
RESIDENTIAL AND OUTPATIENT TREATMENT CENTERS:
Have you been admitted to any treatment centers?* Radio buttons
List the most recent Residential Treatment Center and Dates:
TreatmentCenterHistory  
List the most recent Outpatient Treatment Center and Dates:
TreatmentCenterHistory
LEGAL HISTORY
Have you ever been charged with or convicted of a crime?*
Criminal History
If yes, please give details, crime, dates, what happened:
Paragraph
Are you currently on probation? Radio buttons
If yes, need name and phone number of Probation Officer
Text field

Move-In Information

What date are you requesting to move-in?

How long would you like to stay in supportive housing?

Client estimated length of stay
 Do you currently know anyone at Freedom House for Women?
Text field
 Please list the names and phone numbers of the last 3 Sober Living Homes you were at:
SoberLivingHistory
 
Tell us in your own words, what is different about NOW?
Why should Freedom House for Women, Inc. approve your application?
What is your compeling reason to live in supportive housing at this time? 
Paragraph
 
SIGNED:
SignatureSignature
Date Date