Application for Healing Housing
Today's Date: Date
Date of Birth: Date
Date of Last Use: Date
Full Legal Name: Client first name Client last name
Preferred Pronouns: Text field
Phone Number: Client phone
Home Address: Client Address Client City Client State Client Zip
Email: Client email
Relationship/Marital Status: Client marital status
Highest Level of Education Completed: Text field
Current Location: Text field
Expected Discharge Date from Current Location: Date
Address of Current Location: Text field
Case Manager Name: Text field
Case Manager Contact Information: Text field Text field
Are you currently pregnant? Dropdown
How many children do you have that are under the age of 18? Dropdown
Are they safe? Dropdown
Who will care for your children while you are at Healing Housing? Text field
Are they under the care of DCS? Dropdown
Name of legal guardian: Text field
Legal guardian contact information: Text field Text field
I agree to give Healing Housing written permission to contact the legal guardian
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
What is your history of self-harm (cutting, burning, etc.)? Please include behavior and approximate date(s):
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What is your history with eating disorders? Please include behavior and approximate date(s):
Paragraph
What is your history with violent and/or aggressive behaviors? Please include behavior and
approximate date(s):
Paragraph
When is the last time you considered hurting yourself? What was your plan or attempt? Please indicate approximate date(s):
Paragraph
Are you currently having suicidal or self harm thoughts?:
Radio buttons
Please list previous drug, alcohol, or psychiatric treatment and/or hospitalization:
TreatmentCenterHistory
Please list your current therapist: Text field
Please list your current Psychiatrist: Text field
Please list the age of when you were first exposed to drugs and/or alcohol or when you first
tried these substances.
Text field
Why are you today seeking recovery support housing?
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Medical History:
Who is your Primary Care Physician? Text field
Contact information for PCP: Text field Text field
Date of last physical: Date
Date of last Tuberculosis test: Date
Please list medications you are currently taking:
Name of Medication: Medication
Prescriber Name & Contact Information: Text field Text field Text field
Reason Prescribed: Text field
I agree to give Healing Housing written permission to verify all medications listed above with their associated prescriber
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
Charges:Text field
County: Text field
Pending Court Date(s): Date
Charges: Text field
County: Text field
Pending Court Date(s): Date
Charges: Text field
County: Text field
Pending Court Date(s): Date
Financial Information:
What income do you receive from the follow services each month?
Unemployment benefits: $Text field/month
Self-employment: $Text field /month
Real Estate/Investments: $Text field /month
DSHS/TANF (started when?): $Text field /month
Food Stamps: $Text field /month
Child Support: $Text field /month
Alimony: $Text field /month
SSI/SSDI (currently receive or plan to apply): $Text field /month
Military benefits: $Text field /month
Other: $Text field /month
Emergency Contact:
Name: Text field
Relationship to You: Text field
Phone Number of Emergency Contact: Text field
Email of Emergency Contact: Text field
I agree to give Healing Housing written permission to contact the person listed above
I certify that all of the information on this application is correct to the best of my ability. I voluntarily answered these questions without coercion and am not under the influence of any mood-altering substance.
Signature :
Signature
Date: Date