Application

Sharon's House of Hope Application for Recovery Housing

Welcome to the Sharon's House of Hope Application 
Click next to begin!

General

Tell us about yourself
What is your first name?
Client first name
What is your middle name?
Client middle name
What is your last name?
Client last name
When is your birthdate?
Client birthdate
What is your SSN?
SSN
What is your gender?
Client gender
What is your marital status?
Client marital status
Are you on SSI or disability?
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Do you have food stamps?
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Any other financial assistance?
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Do you have a driver's license? Do you have a vehicle?
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Do you have a copy of your birth certificate and social security card?
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Contact Information

How can we reach you?
What is your email address?
Client email
At what phone number can we best reach you at?
Client phone
Street Address:
Client Address
City:
Client City
State:
Client State
Zipcode:
Client Zip

Contacts

Give us a few people that we can reach out to in case of an emergency.
Contact

Insurance

Do you have Medicaid, Medicare or private insurance?
Insurance

Medical History

Tell us about your medical history.
When was your last relapse date?
Recovery history 1 relapse date
What is your substance(s) of choice? Add multiple by clicking in the box and selecting different options
Client substances of choice
Have you been clinically diagnosed with anything? Add multiple by clicking in the box and selecting different options
Client diagnosis
Do you have any health problems? Add multiple by clicking in the box and selecting different options
Client health problems
What kind of meetings do you attend? Add multiple by clicking in the box and selecting different options
Client kinds of meetings attended
What allergies do you have? No allergies? Move on to the next question.
Client allergies

Have you had any of the following tests?

Medical Tests
 

Medications

List the medications you are currently prescribed.
Medication

Social Dynamics

Tell us about your family/friends dynamics. What area are your from? Are you in a relationship? Where do your family and friends live? Are they supportive of your recovery?
Family Members
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Client Referral Source

 
Who referred you to us?
Client Referred By

Criminal History

 
Do you have a history of any criminal charges? Any upcoming trial dates?
Criminal History
Are you on probation or parole? If so, where and who is your officer?
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Are you in drug court? If so, where and who is your supervisor?
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Sober Living History

Tell us about any sober livings you've previously lived in? Provide names, dates and why you left. Also, what treatment facilities have you been through?
SoberLivingHistory
TreatmentCenterHistory

Employment

Tell us about your employment status.
If you're currently unemployed select "unemployed" under "type"
EmploymentHistory
 
Will you need to obtain employment while living with us?
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Living Arrangement

Tell us about your living arrangement prior to moving into this facility
LivingArrangementHistory

Have you ever lost housing and why?

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EMERGENCY CONTACT

Who should we contact in case of an emergecy?

Contact

Contact

 

Any additional information we should know about you?

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