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: Text field

Gender Identity: Text field

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

Are your children safe? Dropdown

Are they under the care of DCS? Dropdown

 

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

 

Medical

List any allergies: Text field

How would you describe your current health? Dropdown

List any physical health / medical conditions or disabilities: Text field

Do you have a history of seizures? Dropdown

List any medical equipment: Text field

Date of last Tuberculosis Test: Text field

 

Mental Health

List any mental health 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

Have you ever been a victim of 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

Have you ever been charged or convicted of cruelty to animals? 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

Have you previously applied to Healing Housing? Dropdown

Are there any issues that could prevent you from completing the program? Paragraph

How long would you hope to stay at Healing Housing? 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

 

Signatrure: Signature      Date: Date