IORS APPLICATION FOR SERVICES 

YOU MUST PROVIDE CONTACT INFORMATION IN ORDER FOR YOUR APPLICATION TO BE PROCESSED

 

Date:  Date

The following information is considered confidential and will be dealt with as such.  Your complete and honest answers will assist us in determining your eligibility and prevent delays in entering the program.  Intentionally falsifying any answers could result in being disqualified from Inside Out Re-Entry Services. Please fill out the form completely. 

Applicant’s Name:  Client first name Client last name DOB: Client birthdate

Address:  Text field

Client Telephone:  Client phone  Client Email:  Client email

Alias Names Used:  Text field

 

 

Have you ever applied to Inside Out before? Text field If so, When? Paragraph

Have you ever been a resident of any of the Inside Out  houses? Text field If so, When? Paragraph

Do you have children? Yes Text field No Text field With whom and where do they currently reside? Please include their gender and ages.Paragraph

Are you currently or have you ever been involved with social services regarding your children? Text field Yes Text field No

If yes, please explain:  Paragraph

Name and phone number of your case worker:  Text field

Which of the options below best fits your current status with you and your children?

Sole Custody Text field  Joint Custody Text field Guardianship Text field  Adopted Text field

Other:Paragraph

Do you have a Department of Corrections Number Text field Yes    Text field DOC# Text field No

What is your? Projected Release Date:Date

Case Manager Name: Text field Phone Number: Text field Email: Text field

Are you Native American?  Text field Yes Text field No  If yes, what tribe? Paragraph

Do you have a CDIB card? Text field

Explain your need and desire to be selected as a resident for Inside Out Re-Entry Services?

Paragraph

Problems Areas

Are there any legal, medical, financial or relationship issues that could prevent you from completing the program? 

Text field Yes Text field No

Are you the one seeking help and are you willing to accept counsel?  Text field Yes Text field No

Please list any substances or activities to which you are currently or have been addicted to the in the past in order of frequency of use:

Drug Used How Often Used Date Last Used

Text field Text field Text field

Text field Text field Text field

Text field Text field Text field

Alcohol How Often Used Date Last Used

Text field Text field Text field

Have you ever been to a detoxification facility or other treatment program? Text field Yes Text field No

List prior treatment facilities you have entered Paragraph

Date of your last drug/alcohol use: Text field

What did you use?  Paragraph

How long have you been using?  Paragraph

Finish this statement:

With God’s help, as a result of this program, I would like to change my life in the following five areas:

1. Paragraph

2. Paragraph

3. Paragraph

4. Paragraph

5. Paragraph

Have you attended recovery meetings in the past?       Text field Yes Text field No

Have you completed a CR step Study?         Text field Yes Text field No

Location Text field Leader Text field

Do you have a sponsor Text field Phone Text field

 

RELATIONSHIPS

Are you currently: Text field Single Text field Married Text field Separated Text field Divorced?

Do you have a boyfriend or common law spouse? Text field yes Text field no

I understand I will not be allowed to be in a relationship with anyone of the opposite or same sex in any manner during the course of this program. Text field Initials

Can you commit to remain in the program until staff recommends completion? Text field yes Text field no

Do you want to join Inside Out Re-Entry Services? Text field Yes Text field No Do you feel forced to join? Text field Yes Text field No

When you are confronted on issues, how do you normally react?  Paragraph

 

LEGAL HISTORY

Have you ever been arrested? Text field Yes Text field No (If yes, list date of arrest – month/year, reason for arrest and outcome:  Paragraph

Name and phone number of your attorney: Text field

Are you a listed sex offender? Text field Yes Text field No

Do you have any outstanding warrants?  Text field Yes Text field No

If yes, please explain:  Paragraph

Are you on parole or probation?  Text field Yes Text field No If yes, please explain:  Paragraph

Name of probation/parole officer: Text field

Phone Number:  Text field County/State:  Text field

Are you currently incarcerated?  Text field Yes Text field No How many times have you been incarcerated?  Text field

Where? Paragraph

Have you ever been a victim of sex trafficking, or been involved in prostitution? Text field Yes Text field No  If yes, please describe. Paragraph

Have you ever been affiliated with any gang?  Text field Yes Text field No 

If yes, explain your status of said gang:

Paragraph

HEALTH HISTORY (FALSIFYING MEDICAL INFORMATION IS GROUNDS FOR DISMISSAL FROM THE PROGRAM)

Height: Text field Weight Text field Hair Color Text field Eye Color  Text field

Would you say your health is : Text field  Very Good Text field  Good  Text field  Average  Text field  Declining  Text field Poor

Please explain if you listed that your health is declining or poor: Paragraph

Do you have problems in any of the following areas?

Text field Dental  Text field  Back Text field  Neck Text field  Orthopedic (bone) Text field  Heart

Text field High blood pressure Text field  Diabetes Text field  Asthma Text field  Allergies

If yes to any other medical conditions, describe how it impairs your life: Paragraph

Are you currently prescribed medications for these conditions which you are not taking?  Text field  Yes  Text field  No

If yes what medications?  Paragraph 

Do you have any physical limitations that would prevent you from participating fully in the Inside Out Re-Entry Program?

Text field Yes Text field  No

If yes, please explain: Text field

Can you sleep in a bunk bed?  Text field Yes  Text field  No

Name and phone number of your doctor: Text field

Do you smoke?  Text field Yes Text field No   If yes, how many years?  Text field Packs per day? Text field

Would you be willing to quit smoking? Text field  Yes Text field  No

Have you ever overdosed?  Text field Yes Text field No   If yes, when?  Text field

Do you currently or have you ever had an eating disorder?  (Anorexia, bulimia, overeating) Text field Yes Text field No

Were you abused as a child?  Text field Yes Text field No    If yes, what type:  Text field Physical Text field Sexual Text field Verbal

Briefly explain:  Paragraph

Is there a history of mental health disorders in your family?  Text field Yes Text field No

Are you currently a mental health client?  Text field Yes Text field No

If yes, please list your therapist's name and location:  Paragraph

List all mental health medications you have been prescribed and are currently taking: Paragraph

List any mental health medications prescribed that you are not taking and why you stopped taking them:

Paragraph

FAMILY HISTORY

Give a brief description of your childhood home environment:  Paragraph

Text field Father’s  Text field Step Father’s Name  Text field Age:  Text field

Occupation:  Text field

Describe your relationship with him: Paragraph

Text field Mother’s Text field  Step Mother’s  Name: Text field   Age:  Text field

Occupation:  Text field

Describe your relationship with her:  Paragraph

How many siblings do you have:  Text field What place are you in the birth order:  Text field

Describe your relationship with your siblings as you were growing up: Paragraph

Give a brief description of what it was like growing up in your family:  (praise, criticism, punishment, trauma, accomplishment): Paragraph

Were you ever placed in foster care?  Text field Yes Text field No If yes, please explain:  Paragraph

Did your family move a lot?  Text field Yes Text field No If yes, explain:  Paragraph

If there are children or stepchildren in your home, describe your relationship with them:

Paragraph

In the event of an emergency please list the names, address and phone numbers of three people:

Name Text field

Address Text field Phone Text field

Name Text field

Address Text field Phone Text field

Name Text field

Address Text field Phone Text field

 

FINANCIAL ASSESSMENT

The program fees are $125 per week without children and $135 per week with children. There are a limited number of scholarships available for those with extreme hardship situations. The fees are based on a sliding scale and no one will be denied access to the program due to a lack of funds. Financial arrangements will be discussed during the interview.

What is your preferred occupation?  Text field

When were you last employed?  Date

Do you currently have an income?  Text field Yes Text field No

What is your source of income?  Text field Unemployed Text field Disability  Text field Insurance Text field Family

Text field Trust Fund  Text field SSI Text field  Other: Text field

List all of your financial obligations and amounts:  (child support, car payment, restitution, parole/probation, etc)

Paragraph

How will these obligations be met while you are in the program?  Text field

Is there anyone who would be willing to help with your expenses while you are in the program?  Text field Yes Text field No

If you leave the program prior to graduation, you will need to find transportation to other living arrangements.  A friend or family member will need to pick you up or someone will need to provide a bus ticket for you.  You may also bring a bus ticket with you when you arrive:  

Who will be responsible for this?

Name: Text field Day Phone: Text field

Cell:  Text field Address: Text field

Text field I will bring a bus ticket with me when I arrive.

SPIRITUAL ASSESSMENT

Have you been, or are you now affiliated with any organized religion?  Text field Yes Text field No

If yes, what is name & type: Paragraph

Do you currently attend services?  Text field Yes Text field No

If yes, where?  Paragraph

Are you satisfied with your spiritual health?  Text field

Leader’s Name:  Text field

On a separate piece of paper, state in your own words why you need to join Inside Out Re-Entry Services and describe your commitment to change your life.

WAIVERS (initial each of the following)

I understand that Inside Out Re-Entry Services is not a detoxification facility. Text field
I understand that Inside Out Re-Entry Services is not a medical program. Text field
I understand that as part of Inside Out Re-Entry Services, I will be assigned a task assignment and I waive my right to legal action against IORS and its representatives if I am hurt during that task. Text field
I understand that Inside Out Re-Entry Services provides limited transportation to me while participating in the Inside Out Re-Entry Services Program and I waive my right to legal action against Inside Out Re-Entry Services (IORS) and its representatives if injured while being transported by any of the ministry's vehicles.  Text field
I understand that Inside Out Re-Entry Services is not a licensed treatment center and I waive my right to legal action against IORS if staff or volunteers based on any counsel I receive. Text field

Applicant’s Signature:  Signature

Date:  Date