***IF YOU HAVE ALREADY INTERVIEWED, USE THE INTAKE FORM & CONTRACT - DO NOT USE THIS FORM PLEASE.***

Acceptance Homes Pre-Screening Form

General Information:

First Name: Client first name 

Middle Name: Client middle name 

Last Name: Client last name

Prior Address: Client Address

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

Prior County: Text field

Email: Client email Phone Number: Client phone

Gender: Client gender Birthdate: Client birthdate

Marital status: Client marital status

Race: Client race Ethnicity: Client ethnicity

Veteran: Client veteran

Desired Move in Date: Date Expected Duration of Stay: Client estimated length of stay

 

Do you have support to pay for the first month's program fee until funding is approved?

Radio buttons

Medical History

Diagnosis: Client diagnosis Health problems: Client health problems

Referred by: Client referred by Referral source: Client referral source

Counselors Direct Contact Number: Contact

Counselor - Please send Psych/Social to AcceptanceHomesLLC@gmail.com, if available.

 

Are you on MATs (Medically Aided Treatments)? Radio buttons

What other medications are you on (Failure to list all medications will lead to dismissal from the program)? Medication

How would you rate your personal health?

Checkboxes

Have you ever had suicidal thoughts? Dropdown

Have you ever had homicidal thoughts? Dropdown

Do you consider yourself an addict/alcoholic? Radio buttons

How many times have you been to rehab? Text field

What's the longest you've been clean before? Text field

Have you tried 12 step programs before? Dropdown

Do you have a sponsor? If so, who? Text field

Before calling this recovery house, have you attempted to get into a halfway house? Radio buttons

IF NOT, WHY NOT? Paragraph

IF YES, WHAT WAS THE RESULT? Paragraph

CRIMINAL HISTORY

 

Have you ever been convicted of a crime? Radio buttons

IF YES, PLEASE EXPLAIN:

Paragraph

Are you required to register as a sex offender? Radio buttons

Do you have warrants for your arrest? Radio buttons

Do you currently have a probation or parole officer? Radio buttons

 

Application Agreement and Signature

Attestation - I attest that all of the information is complete and accurate. I acknowledge that failure to provide complete and accurate information could result in legal consequences including, but not limited to, termination of residency from the Acceptance Homes LLC program.

Release of Information - By signing below, I am providing my approval for Acceptance Homes LLC releases to discuss my medical, treatment, and progress information with my probation/parole officer (if applicable), my emergency contact, the counselor listed above, and Lawrence County Drug and Alcohol Commission Inc.

By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.

Signature

Printed Full Name: Client first nameClient last name

Today's Date: Date