Client first name Client last name Text field Client Address
Contact
Current Location: Text field
Expected Discharge Date: Text field
Case Manager Name: Text field
Case Manager Phone Number: Text field
Case Manager Email Address: Text field
Emergency Contact Name: Text field
Emergency Contact Phone Number: Text field
Demographics
Sex at Birth: Text field
Gender Identity: Text field
Ethnicity: Dropdown
What is the highest level of education you completed? Text field
What is your primary language? Text field
Are you a veteran? Dropdown
Family
Are you fleeing a domestic violence situation? Dropdown
Do you have children? Dropdown
Age of children: Text field
Do you have legal custody of your children? Dropdown
What are your minor children's current living arrangements? Text field
Are your children safe? Dropdown
Is there DCS involvement? Dropdown
If so, what is required of your parenting plan? Text field
Substance Use History
Drug(s) of Choice: Checkboxes
For how many years have you been using alcohol and/or drugs? Text field
What is your date of last use? Text field
What is your sobriety date? Text field
List any previous times of recovery (best estimate of dates): Text field
Medical
List any allergies: Text field
How would you describe your current health? Dropdown
Do you have any concerns about your current health that you would like to address? If so, explain. Text field
Do you have any chronic medical (physical) conditions or disabilities that interfere with your day-to-day tasks? If so, explain. Text field
Do you have a history of seizures? Dropdown
List any medical equipment or aids: Text field
Tuberculosis Screening
Date of last Tuberculosis Test: Text field
Have you lived or traveled for more than 2 months in Asia, Africa, Central or South America, or Eastern Europe? Dropdown
Were you born on one of these continents? Dropdown
Have you ever been vaccinated with BCG (Bacillus Calmette-Guerin)? Dropdown
Have you ever had a positive TB skin test or history of active tuberculosis infection? Dropdown
Has anyone living in your household ever had a history of active tuberculosis? Dropdown
Have you worked, volunteered, or lived in a nursing home, hospital, homeless shelter, prison, or other healthcare facility? Dropdown
Have you experienced any of the following symptoms in the last 30 days?
Checkboxes
Mental Health
List any mental health diagnosis and when you received each diagnosis: Text field
Please describe any history of self-harm: Paragraph
Please describe any history of suicidal ideation, attempts, or inpatient psychiatric stays: Paragraph
Please describe any history of disordered eating: Paragraph
Do you have a hisotry with human or sex trafficking? Dropdown
Describe any involvement with violent and/or aggressive behaviors: Paragraph
Medication
Please list all prescription medication(s): Paragraph
Please list all over-the-counter medication(s) that are taken regularly: Paragraph
Please list any drug replacement medication(s): Paragraph
Treatment History
Please list all previous treatment centers and dates: Paragraph
Courts & Criminal Justice
Are you currently involved in any legal proceedings or criminal justice issues? Dropdown
Do you have any pending sentencing or possible jail time upcoming? Dropdown
Have you ever been charged or convicted of Arson? Dropdown
Have you ever been charged or convicted of any violent crimes in any jurisdiction? Dropdown
Have you ever been charged or convicted of abuse or neglect of any person, including but not limited to disabled persons, seniors, or children? Dropdown
Are you affiliated with any gang? Dropdown
Are you required to register as a sex offender? Dropdown
Are there any Restraining Orders or Orders of Protection against you or by you? Dropdown
Admissions
Do you have a personal relationship with anyone who works for Healing Housing? Dropdown
Do you know anyone currently in the Healing Housing program? Dropdown If so, who? Text field
Have you previously been a participant at Healing Housing? Dropdown
Are there any issues that could prevent you from completing the program? Paragraph
Healing Housing is a 1-year program. Are you willing to commit to staying for 1 year? Dropdown
Client Statement
Please describe what led you to seek housing with Healing Housing. Be specific as to details such as how, when, where, and your personal responsibility: Paragraph
Why do you think you are a good fit for sober living? Paragraph
What do you want to accomplish while residing at Healing Housing? Paragraph
Employment:
Are you able to work at least 32 hours a week? Dropdown
Are you currently employed? Dropdown
Describe your work history: Paragraph
Additional Info
Please enter any other information about yourself or your situation that you feel we need to know: Paragraph
Signature: Signature Date: Date