Housing Intake Form

Housing Intake Form

 

Client first nameClient middle nameClient last name

Client email

SSN

Client Address

Client Address

Client City  Client State Client Zip

Client phone

Client email

Client admit date

Client race  Client ethnicity  Client marital status  Client veteran status

 

Primary Emergency Contact

Include the contacts full address in the notes section

Contact 

 

Secondary Emergency Contact

Include the contacts full address in the notes section

Contact

 

Referral Information

Client Referred By

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Reason For Referral

Chief complaint and symptoms (please be very specific including issues at home/school related to substance abuse).

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Financial Responsibility

I will be responsible for my own program fees & rent:

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Are you employed?

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If Yes, who is your employer

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Will you have support from family for program fees & rent?

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Will you have a car at the house?

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Will you be enrolled in school?

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Drug/Alcohol Use History

Do you have a history of alcohol and drug abuse?

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Do you take prescription medication?

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List all allergies and medical conditions:

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Legal History

Do you have any pending court cases?

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If Yes, Please list upcoming court dates and the name and contact information of your attorney

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Have you ever been accused of or convicted of a sexual offense or violent crime?

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If Yes, please list the nature of the crime, date of the crime, and any other information you deem necessary

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Previous Treatment Centers

Please list the names of treatment centers, dates of stay, and reasons for leaving

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What goals do you have while you are at Shepherd's House in which we can support you?

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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.

 By signing below, I agree that I have read and will abide by the rules of the house.

Signature Date