SCREENING APPLICATION:

 

 

Non-Discrimination Policy

In the Meantime is committed to providing a safe, supportive, and inclusive environment for all individuals seeking recovery. We do not discriminate on the basis of race, color, national origin, religion, sex, gender identity or expression, sexual orientation, age, disability, marital status, veteran status, or any other characteristic protected by applicable law.

Our facility welcomes all women who meet our admission criteria, and we strive to create a community that fosters mutual respect, dignity, and empowerment. Discriminatory behavior, harassment, or any form of bias will not be tolerated within our residence.

If you believe you have experienced or witnessed discrimination while applying for or residing in our program, please report it to the Executive Director or a designated staff member for prompt review and resolution.

By submitting this application, you acknowledge and agree to abide by this policy while residing at In the Meantime.

General

First Name: Client first name 

Middle Name: Client middle name 

Last Name: Client last name

Address: Client Address

City: Client City State: Client State Zip: Client Zip

Email: Client email Phone Number: Client phone

Gender: Client gender Birthdate: Client birthdate

Marital status: Client marital status

Race: Client race

Veteran: Client veteran status

 

Desired Move in Date: Date

 

Medical History

Diagnosis: Client diagnosis Health problems: Client health problems

Substance of Choice: Client substances of choice

Kinds of meetings attended: Client kinds of meetings attended

Allergies: Client allergies 

Recovery date: 

RecoveryHistory

Referral source:

 Client Referred By

Licence number Text field SS#SSN

Insurance Information:

Insurances

Are you receiving welfare, unemployment compensation, disability payments, workman’s comp, alimony, VA benefits, or other income?

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Explain: Paragraph

 

How would you rate your personal health?

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HAVE YOU EXPERIENCED OR DO YOU PRESENTLY HAVE A PHYSICAL AILMENT, INJURY, HANDICAP OR MEDICAL PROBLEM THAT WOULD PREVENT YOU FROM PERFORMING PHYSICAL TASKS OR ACTIVITIES OF DAILY LIVING WHILE ENROLLED AT 'IN THE MEANTIME' ?

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IF YES, PLEASE EXPLAIN:

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Intake Coordinator notes:

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