Wilson House of Naples

Resident Application

 

First Name Client first name Middle Name Client middle name Last Name: Client last name

Admission Date Date Date of Birth Client birthdate

Gender:  Client gender

Phone No Client phone Email AddressClient email

Home Address: Client Address City: Client CityState: Client State Zip:Client Zip

Do you own a vehicle?    Radio buttons    

If yes…Year? Number field Make?Text field Model?Text field Color:Text field

License Plate Info:  State: Text field Plate Number:Text field Expiration Date (mo./yr.):Number field/Number field

Insurance Co: InsurancesPolicy #: Text fieldExpiration Date: Date

NOTE: Please provide staff with DL, registration and car insurance paperwork Copies will go in your file.

How did you hear about Wilson House of Naples?Client Referred By

Do you identify as someone who struggles with drugs and/or alcohol? Checkboxes

Do you plan on working a program of recovery while at Wilson House of Naples (12 Step based)? Checkboxes

Are you attending or will you be attending an IOP/OP Program?    Radio buttons         

If so…Program Name: Client facility(Please add to ROI in section below)

 

Medications:

Medication

Medical History/Issues:Client health problems

Have you ever been diagnosed with a mental illness?  Checkboxes

If so, state diagnosisClient diagnosis

Do you have any present or past physical problems?  Checkboxes

If so, state diagnosis_Client diagnosis

Do you have any known allergies?  Checkboxes

If yes, please describe what the allergy is, what happens if you become afflicted, and what remedy should be taken. Client allergies

Are you currently under the care of a physician?Checkboxes

If so, reason Client diagnosis

Physician’s Name Text field Phone No Text field

Currently working?  Radio buttons    If so, where? Text field

Address Text field

  Phone No Text field

Emergency Contacts ( Including Financial Contact (the person helping you out financially – if you are self-supporting please leave blank))

Contact

Substance Abuse Facility / Sober Housing History

SoberLivingHistory

 

Sobriety Date:RecoveryHistory

Drug of choice:Client substances of choice

List Recent Drugs Used

DRUG:  Text field DATE OF LAST USE: Date

DRUG:  Text field DATE OF LAST USE: Date

DRUG:  Text field DATE OF LAST USE: Date

DRUG:  Text field DATE OF LAST USE: Date

Criminal History

Have you ever been convicted of a felony or misdemeanor:  Criminal History

If yes please explain:

Paragraph

Sex Offender / Predator Status:      Radio buttons

If yes please explain: Paragraph

Convicted of crimes of violence or sexual in nature against the elderly, children, or the disabled: Radio buttons

If yes please explain:

Paragraph

Resident Signature Signature  Date: Date

Resident Print Name Text field  Date Date

Staff Name Text field

Staff Signature Signature

By signing this document, I attest that all above information is true and accurate to the best of my knowledge. I also agree to have my photograph taken to be used for internal staff purposes only.

*NOTE: Residents are to add Wilson House of Naples phone number to their phone contact list. Wilson House of Naples staff is to add the new resident’s cell number as well.

*NOTE: Please be sure to attach any required supporting documentation for residents owning vehicles