Application
 


Doors of Hope

Welcome to the Doors of Hope Intake 

Please email Samantha Bennett to schedule a phone interview: sbennett@opendoorsofhope.org 

Or call Monday - Thursday to schedule. 615-265-2067

Click next to begin!

General

Personal Details
What is your first name?
Client first name
What is your middle name? No middle name? Move on to the next question.
Client middle name
What is your last name?
Client last name
Have you been known by an alternate name?
Dropdown
If yes, what other names did you go by?
Text field
When is your birthdate?
Client birthdate
Social Security Number?
Text field
What is your race/ethnicity?
Client race
What is your gender?
Client gender
What is your marital status?
Client marital status
Are you a veteran?
Client veteran status
What county/city are you from?
Client CityClient StateClient Zip
Where are you currently at? 
Client Address
Client CityClient StateClient Zip
Release, Discharge Date?
Text field
Court Date?  
Date

Contact Information

We use the Cell Phone Number & Email below to text or email you the full application form.

Please provide at least one of the following Contact Details:

What is your email address?
Client email
Cell Phone Number
Client phone
Landline line number
Client phone
 
Consent to contact 
I consent to be contacted by Doors of Hope Transitional Living via SMS, email, or phone using the information I provided for the purposes of reviewing my application.
Checkboxes

Contacts

Give us at least two people that we can reach out to in case of an emergency.
Contact
Contact

Demographics

Sex assigned at birth
Client gender

What is the highest level of education you completed?

Text field

What is your primary language?

Text field

What are your preferred pronouns?

Client pronoun

Have you previously been part of Doors of Hope program?

Checkboxes

What is your marital status?

Client marital status

Are you fleeing a domestic violence situation? If yes please explain.

Checkboxes

Paragraph

Do you have children? Names, Ages, and who they live with?

Paragraph

 

 

Insurance

Enter your insurance provider(s).
Insurance

Substance Use History

Tell us about your current history.
When was your last relapse date?
Recovery history 1 relapse date
What is your sobriety date?
Date
What is your substance(s) of choice? Add multiple by clicking in the box and selecting different options
Client substances of choice
Please include the all of the following, How long have you been using substances, What age did you first use for each substance, and what method did you use for each substance (oral, nasal, iv).
Paragraph
Do you use tobacco?
Checkboxes
What kind of meetings do you attend? Add multiple by clicking in the box and selecting different options
Client kinds of meetings attended
How many meetings have you attended in the last 30 days?
Number field
 

Mental Health History

Tell us about your current history.
 
Have you been clinically diagnosed with anything? Add multiple by clicking in the box and selecting different options
Client diagnosis
Do you have a history of self-harm?
Checkboxes
Have you ever experienced any suicidal ideations, attempts, or received in-patient treatment for self-harming behaviors?
Checkboxes
Do you have an Eating Disorder or Body Image Disorder?
Checkboxes
Have you ever been a victim of sex trafficking?
Checkboxes
Have you ever been involved in prostitution?
Checkboxes
Do you see or hear things that are not really there? If yes, please explain.
Paragraph

Medical History 

Tell us about your current history.

Do you have any health problems? Add multiple by clicking in the box and selecting different options
Client health problems
What allergies do you have? No allergies? Move on to the next question.
Client allergies
Are you currently under the care of any of the following provider types? Check all that apply.
Checkboxes
How would you describe your current health?
Dropdown
Do you have a history of seizures? 
Checkboxes
Do you have any upcoming appointments or ongoing physical needs?
Checkboxes
Do you have any medical equipment?Add multiple by clicking in the box and selecting different option
Checkboxes Other: Text field
Any chronic health concerns? (Lungs, heart, liver, kidney disease, diabetes)
Paragraph
Are you able to walk long distances, walk up and down stairs, stand for long periods of time?
Checkboxes
Any previous brain injuries? If yes, please explain.
Checkboxes
Paragraph
Do you have a learning disability or difficulty reading?
Checkboxes

Have you had any of the following tests?

Medical Tests
Do any of the following apply to you? Add multiple by clicking in the box and selecting different options
Checkboxes
Are you currently pregnant?
Checkboxes
If yes to any of the following please explain.
Paragraph

Medications

List the medications you are currently prescribed.

Paragraph
Are you currently using any over-the-counter medications?
Checkboxes
Are you participating in or about to enter MOUD or MAT services (drug replacement programs)?
Checkboxes
 

Courts & Criminal Justice


Do you have an attorney? 
Checkboxes
Are you currently involved in any legal proceedings or criminal justice issues? 
Checkboxes

Do you have a requirement for Community Service? 
Checkboxes
Do have any court ordered treatment requirements? 
Checkboxes
Do you have any pending sentencing or possible jail time upcoming? 
Checkboxes
Do you have a Department of Corrections Number? 
Checkboxes
Have you ever been charged or convicted of Arson? 
Checkboxes
Age of first arrest? 

Text field
How many times have you been arrested? 

Number field
Have you ever been charged with anything aggravated? Explain. 

Paragraph
Provide attorneys name, email, and phone number. 

Paragraph
Are you banned from any stores or businesses? Explain.

Paragraph
Do you have any holds or warrants in another county or state?  

Paragraph

Select all legal requirements that apply.

Checkboxes

Are you required to register as a sex offender? 
Checkboxes
Are there any Restraining Orders against you or by you? 
Checkboxes
Have you been arrested in the last 30 days?

Checkboxes
Have you ever had a DUI?

Checkboxes
If yes, what county, what number DUI, and is it current? 

Paragraph
How long has it been since you've been released jail?  

Text field

Admissions

When would you live to move in?

Date

Do you have a personal relationship with anyone that works for Doors of Hope Transitional Living?

Checkboxes

Have you previously applied to Doors of Hope Transitional Living?

Checkboxes

Are there any issues that could prevent you from completing the program?

Checkboxes

Why do you want to live in a sober house?

Paragraph

How did you hear about about our program?

Paragraph


THIS QUESTION MUST BE ANSWERED FOR APPLICAITON TO BE REVIEWED Describe what issues led you to seek housing with Doors of Hope Transitional Living. Be specific as to details such as how, when, where and your personal responsibility.

Paragraph

Please enter any other information about yourself or your situation that you feel we need to know.

Paragraph

 

Treatment Centers

Tell us about any treatment centers you've previously been admitted into.
TreatmentCenterHistory

Client Referral Source

 

Were you referred to Doors of Hope Transitional Living?

 Checkboxes

Who referred you to us?
Client Referred By

 

Employment

Tell us about your employment status.
If you're currently unemployed select "unemployed" under "type"
EmploymentHistory
Are you able to work?
Checkboxes
Are you willing to work 40 hours a week of gainful employment?
Checkboxes
Do you understand that it is $150 per week once you recieve your first paycheck?
Checkboxes
Do you currently have an income?
Checkboxes
What are your current weekly expenses? (food, car payment, child support, etc)
Paragraph
 

Living Arrangement

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