Application for Healing Housing

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

Phone NumberClient phone

Home Address: Client Address Client City Client State Client Zip

EmailClient email

Relationship/Marital Status: Client marital status

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

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):

Paragraph

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?

Paragraph

 

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

DateDate