Application for Residency

 

 

H.I.R House Application 

Welcome to the H.I.R. House application 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 Social Security#?
SSN
What is your race?
Client race
What is your ethnicity?
Client ethnicity
What is your gender?
Client gender
What is your marital status?
Client marital status
Are you a veteran?
Client veteran

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

Enter your insurance provider(s).

Insurance

Legal Information

Tell us about any current or prior legal issues.

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Probation

Criminal History

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
Do you have a Sponsor?
Client sponsor
What allergies do you have? No allergies? Move on to the next question.
Client allergies
Who is your current therapist?
Therapist/Clinician
Counseling History
 

Have you had any of the following tests?

Medical Tests
 

Medications

List the medications you are currently prescribed.
Medication

Treatment Centers

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

Client Referral Source

 
Who referred you to us?
Client Referred By

Occupancy

What facility will you be staying at?
Client facility
What date will the you be admitted on?
Client admit date
What is the estimated length of stay?
Client estimated length of stay
When will the you be discharged?
Client discharge date

Sober Living History

Tell us about any sober livings you've previously been admitted into.
SoberLivingHistory

Education

Tell us about your education.
______________________________________________________________________________________________________________________________________________________________________________________

EducationHistory

Employment

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

Living Arrangement

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

______________________________________________________________________________________________________________________________________________________________________________________

LivingArrangementHistory

Additional Questions

Tell us a little about yourself...

______________________________________________________________________________________________________________________________________________________________________________________

What would you like to accomplish during your stay here?

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What are your top 3 goals and why?

Paragraph

What potential challenges do you see in maintaining your recovery?

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What else would be helpful for us to know about to best support you?

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Do you have a sponsor?

Client sponsor

If you attend a 12 step program, what step are you on?  Text field

 I, Client first name Client last name, verify that all the information provided is true and correct to the best of my ability

Applicant Signature:  Signature Date: Date

By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.