Application for Healing Housing

Application for Healing Housing

 

Date: Date

Date of Birth: Date

Sobriety Date: Date

Full Legal Name: Client first name Client last name

Marital Status: Client marital status

SS#: Text field

Current Location: Text field

Expected Discharge Date from Current Location: Date

Phone Number: Client phone

Address: Client Address

Are you Currently employed?

Radio buttons

If so, include employer and schedule:Paragraph

Do you have children?

Radio buttons

If so, include the child’s age, the name of the child’s legal guardian, and where the child is currently living.

Paragraph

Treatment & Mental Health History:


What is your drug(s) of choice? 

Client substances of choice

Please list any mental health diagnoses you have received (Depression, PTSD, etc.):

Client diagnosis

Do you have a history of self-harm (cutting, burning, etc.)? If so, include behavior and date:

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Do you have a history of an eating disorder? If so, include behavior and date?

Paragraph

Have you ever engaged in violent/aggressive behaviors? If so, include behavior and
approximate date(s):

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Do you have a history of suicidal ideation with a plan/attempts? If so, please indicate
approximate date(s):

Paragraph

Are you currently having suicidal ideations?: 

Radio buttons

 

Please list previous drug, alcohol, or psychiatric treatment and/or hospitalization:

Treatment Center #1

Name: Treatment center 1 name

Admitted: Treatment center 1 started 

Discharged: Treatment center 1 ended

Reason for seeking treatment: Treatment center 1 notes

 

Treatment Center #2

Name: Treatment center 2 name

AdmittedTreatment center 2 started

DischargedTreatment center 2 ended

Reason for seeking treatment: Treatment center 2 notes

 

Treatment Center #3

NameTreatment center 3 name

AdmittedTreatment center 3 started

DischargedTreatment center 3 ended

Reason for seeking treatment: Treatment center 3 notes

 

Treatment Center #4

NameTreatment center 4 name

AdmittedTreatment center 4 started

DischargedTreatment center 4 ended

Reason for seeking treatment: Treatment center 4 notes

 

Treatment Center #5

NameTreatment center 5 name

AdmittedTreatment center 5 started

DischargedTreatment center 5 ended

Reason for seeking treatment: Treatment center 5 notes

 

 

Please list your current therapist: Text field

Please list your current Psychiatrist: Text field

 

Emergency Contact:

Name:Contact 1 name

Type: Contact 1 type

Relationship to You: Text field

Phone Number:Contact 1 phone

Email:Contact 1 email

 

Please list the age of when you were first exposed to drugs and/or alcohol or when you first
tried these substances.

Text field

 

Medical History:

Please list your primary care physician & contact information:

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Medication

Medication #1

MedicationMedication 1 name Dosage: Medication 1 dosage

QuantityMedication 1 quantity CategoryMedication 1 category

FrequencyMedication 1 frequency MDMedication 1 md

Pill count: Medication 1 pill count Discontinued at: Medication 1 discontinued at

NotesMedication 1 notes

 

Medication #2

MedicationMedication 2 name DosageMedication 2 dosage

QuantityMedication 2 quantity CategoryMedication 2 category

FrequencyMedication 2 frequency MDMedication 2 md

Pill count: Medication 2 pill count Discontinued at: Medication 2 discontinued at

Notes: Medication 2 notes

 

Medication #3

Medication: Medication 3 name DosageMedication 3 dosage

QuantityMedication 3 quantity CategoryMedication 3 category

Frequency: Medication 3 frequency MDMedication 3 md

Pill count: Medication 3 pill count Discontinued at: Medication 3 discontinued at

NotesMedication 3 notes

 

Medication #4

MedicationMedication 4 name DosageMedication 4 dosage

QuantityMedication 4 quantity CategoryMedication 4 category

Frequency: Medication 4 frequency MD: Medication 4 md

Pill count: Medication 4 pill count Discontinued at: Medication 4 discontinued at

Notes: Medication 4 notes

 

Medication #5

Medication: Medication 5 name DosageMedication 5 dosage

Quantity: Medication 5 quantity Category: Medication 5 category

Frequency: Medication 5 frequency MD: Medication 5 md

Pill count: Medication 5 pill count Discontinued at: Medication 5 discontinued at

Notes: Medication 5 notes

 

Legal Information:

DOC History (if applicable)
DOC # Text field Location: Text field

Release date: Date

Probation/Parole Information (if applicable)
Will you or do you currently report to:

Checkboxes

How often do you report? Text field

Location: Text field
County/State: Text field

Name of Officer: Text field
Community Hours? (if yes, include number per week/month): Text field

Pending Charges
List any pending charges or warrants including the offense, jurisdiction, and any upcoming court
dates:

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Financial Information:

What income do you receive from the follow services each month?

Current jobEmployer 1 name $Employment 1 income /month

Unemployment benefits: Text field $ Text field/month

Self-employment: Text field $ Text field /month
Real Estate/Investments: Text field $ Text field /month
DSHS/TANF (started when?): Text field $ Text field /month
Food Stamps: Text field $ Text field /month
Child Support: Text field $ Text field /month
Alimony: Text field $ Text field /month
SSI/SSDI (currently receive or plan to apply): Text field $ Text field /month
Military benefits: Text field $ Text field /month
Other: Text field $ Text field /month

List all debts, legal judgements, and other financial obligations you have, including amounts:

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I certify that all of the information on this application is correct to the best of my ability.

Signature :

Signature

DateDate