LIGHT OF HOPE MISSISSIPPI INTAKE FORM

Resident Information 

Full Name: Client first nameClient middle nameClient last nameClient nickname

Cell Phone Number: Client phone

Phone Number if in a Treatment Facility: Text field

Social Security Number: SSN

What form of ID you currently have: Dropdown

Email Address: Client email

DOB: Client birthdate

What is your anticipated length of stay at Light of Hope Mississippi: Text field

Are you willing to commit to a minimum of 2 months at Light of Hope Mississippi: Radio buttons

If no, please describe why: Paragraph

What is your anticipated admission date: Date

Give a brief statement why you are seeking Sober Living: Paragraph

Are you willing to submit to random drug testing: Radio buttons

RecoveryHistory

LivingArrangementHistory

 

Have you resided in a sober living home(Residential), Intensive Outpatient Program (IOP), cooperative education program (OP) or Detox cent in the past: Radio buttons

IF YES PLEASE FILL IN HISTORY

TreatmentCenterHistory

Do you have a significant other: Client marital status

If yes, answer the questions below. If no, write N/A or leave them blank. 

Name of significant other: Text field

Relationship: Text field How Long: Text field

Does your significant other use drugs or alcohol, even socially: Radio buttons

If yes, what: Client substances of choice

Is your significant other supportive of your recovery and supportive of your willingness to enroll in the program at Light of Hope Mississipppi: Radio buttons

Do you want to sign a "HIPAA release form, also known as a HIPAA authorization form, which is a document that allows a patient to give LOHMS permission to share their protected health information (PHI) with others Radio buttons

Do you have any children: 

If yes, please list their first names and ages only: 

Paragraph

Who is caring for your children while you are in sober living: Text field

If you are involved with the court system regarding your children, or have an open case with CPS or DHS, please provide the relevant information below: Child Welfare History

If yes, please describe: 

Paragraph

Contacts for Emergency, Family, Sponsor Ect. Contact

Do you have a support network you already attend: Radio buttonsDropdown

If yes, how many women do you have in your network: Text field

Are you willing to attend weekly meetings and engage in recovery: Radio buttons

Are you currently seeing a Therapist / Clinician or have a couseling history? Radio buttons

If Yes please fill in information or if not applicable skip.

Therapist/Clinician

Counseling History

Medical Information

Please choose Client health problems

Do you currently have a physician who manages your medications: Radio buttons

If Yes, please fill in Contact info below. If NO, referrals will be given to you. Contact

Are you currently on any Medications? Radio buttonsIf yes, please list in the space below: Medication

Do you have any medical issues that would interfere with working or volunteering at least 25 hours a week: Radio buttons

If yes, please explain in detail: Paragraph

Do you have any physical limitations? Are you able to care for yourself AKA showering, walking, cooking, cleaning, etc: Radio buttons

If you have physical limitations please describe: Paragraph

Have you ever attempted suicide: Radio buttons

If Yes, please describe below including dates: Paragraph

Have you ever been Baker Acted to a psychicatric facility: Radio buttons

If Yes, when and describe: Paragraph

Eating Disorders

Have you ever been diagnosed with an eating disorder or nutritional problem: Radio buttons

If yes, please describe: 

Paragraph

Legal Issues 

ProbationCriminal History

Do you have any current pending legal issues: Radio buttons

If yes, describe in detail below, including any upcoming court dates: 

Paragraph

Do you have a history of arrests: Radio buttons

If so, list the year and charges below: 

Paragraph

 Fees 

*We understand that finances may be difficult at the time of submiting this application and we work with each person diffrently to help get you the help you need so please dont be discouraged about the Fee's upfont if an issue. 

Admin Fee: $125 which includes: Intake interview, intake processing, and drug testing.

Deposit $125 Non-Refundable Deposit is fully refundable after 6 month commitment is met or discharge on good standings.

Weekley Rent $125 (you get a 2 week Grace period when moving in but it will be assecesesd to you total bill and can be paid at a later date)

We can also offer you a way to start a savings plan for when you are ready to be on your own again 

I understand in the event of being dismissed from the Light of Hope Mississippi, Inc for any reason including relapse I understand that any deposit or pre-paid fees will be forfeited. Initials Text field

I understand if I do not complete my 6 month commitment to the Light of Hope Mississippi, Inc. I understand that any deposit or pre-paid fees will be forfeited. Initials Text field

All information disclosed is completely confidential. A phone assessment or intake appointment will be scheduled prior to admission to the Light of Hope Mississippi. If you have any further questions please call us at 601-385-1024 or you can visit or our website at www.lightofhopems.com

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 of Applicant: Signature Date:Date

Printed Name: Client first nameClient middle nameClient last name

CPSS Signature: Signature Date:Date

Printed Name: Text field