Sisu Living House Transitional Living Application Form

Empowering New Beginnings On The Journey To Freedom & Wholeness

Welcome to the Sisu Living House intake wizard
Click next to begin!

General

Tell us about yourself
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
When is your birthdate?
Client birthdate
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
Do you have children? If yes, please list the date of birth for each child and beside the date of birth note if the child was born male or female.
(For example: 1/1/2018 - Male; 3/15/2020 - female).
Text field
If no, are you pregnant? If yes, please list the number of weeks of your current pregnancy.
Text field

Contact Information

How can we reach you?
What is your email address?
Client email
What is the best number for us to call you?
Client phone
Street Address:
Client Address
City:
Client City
State:
Client State
Zipcode:
Client Zip

Licence number Text field SS#Text field *we will request a copy of your driver's license or a form of identification.

Contacts

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

Insurance

Enter your insurance provider(s).

Health Insurance: 

Checkboxes

Health Insurance Policy

Provider: Client insurance provider Insurance Plan: Client insurance plan

Group ID: Client insurance group ID Policy#: Client insurance policy #

Address:(Street) (City) (State) (Zip) Text field

Medical History

Tell us about your medical history.
 
Have you been clinically diagnosed with anything (medical or mental health)? 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 allergies do you have? No allergies? Move on to the next question.
Client allergies

Have you had any of the following tests?

Medical Tests

How would you rate your personal health?

Checkboxes

HAVE YOU EXPERIENCED OR DO YOU PRESENTLY HAVE A PHYSICAL AILMENT, INJURY, HANDICAP OR MEDICAL PROBLEM THAT WOULD PREVENT YOU FROM PERFORMING MANUAL LABOR WHILE ENROLLED AT SISU LIVING HOUSE?

Checkboxes

IF YES, PLEASE EXPLAIN:

Paragraph

Medications

List the medications you are currently prescribed.
Medication

Recovery / Behavioral Health History

Tell us about any substance use disorder or behavioral health history. 
RecoveryHistory

Tell us about any treatment centers you've previously been admitted to:
TreatmentCenterHistory
 
When was your last relapse date?
RecoveryHistory

What is your soberiety date:

Client sobriety date

What is your substance(s) of choice? Add multiple by clicking in the box and selecting different options

Client substances of choice

What kind of meetings do you attend? Add multiple by clicking in the box and selecting different options
Client kinds of meetings attended
 

Client Referral Source

Who referred you to us?
Client Referred By

Occupancy

What date do you hope to have bed placement at Sisu Living House?
Client admit date
How long will you need transitional living at Sisu Living House?
Client estimated length of stay
When do you believe you will exit Sisu Living House?
Client discharge date

Employment

Tell us about your current employment status.
If you're currently unemployed select "unemployed" under "type"
EmploymentHistory

Are you receiving welfare, unemployment compensation, disability payments, TANF, workman’s comp, alimony, VA benefits, Medicaid TCL funding, or other income (including work for cash payment)?

Checkboxes
Explain: Paragraph

Living Arrangement

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