SPERANZA HOUSE PROGRAMMING APPLICATION

RESIDENTIAL/ NON-RESIDENTIAL SERVICES

Today's Date: Date

Client's Name: Client first nameClient middle nameClient last name

Date of Birth: Client birthdate   Social Security #: SSN

Height: Text field        Weight: Text field

Email: Client email   Phone #: Client phone

Address: Client Address

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

If incarcerated, please provide an additional contact name/ number, so that we can set up an interview with you: Text field

Current Relationship Status: Checkboxes

Note: If you are not married, Speranza residents will be expected to stay single during the complete duration of our residential program.

How many children do you have: Text field   Ages: Text field   Do you have a current DCS case: Checkboxes

If yes, please give a brief explanation: Paragraph

DCS Caseworker Name/Agency/Phone Number: Text field

What is your highest level of education: Checkboxes

Date of last substance use: Date   What is your drug(s) of choice: Client substances of choice   If marked Other: Text field

Do you have a valid Driver's License: Checkboxes   What is your DLN: Text field

Do you have any physical or learning disabilites: Checkboxes   If yes, please explain: Text field

Were you referred to Speranza House: Checkboxes   If yes, who referred you: Text field

Why are you motivated to be in our program: Text field

Are you eligible for Recovery Works Funding: Checkboxes

Are you currently incarcerated: Checkboxes   If yes, what facility: Text field

Have you ever been incarcerated for any of the following (check all that apply): Checkboxes

Please give a brief explanation for any of the above checked: Paragraph

Do you have any felony convictions: Checkboxes   If yes, felony(s) level: Text field

County(s)/State(s) of conviction(s): Text field

Are you currently on (check all that apply): Checkboxes   If marked other, please explain: Text field

County(s) of Placement: Text field   Name of Officer(s): Text field

Do you have a history of DOC Incarceration: Checkboxes   If yes, in what facility(s): Text field  

Do you have a pending criminal charge(s): Checkboxes   County(s) of pending charge(s): Text field

 

Please give a brief explanation of any pending charges and upcoming court dates: Paragraph

Do you have an attorney: Checkboxes   If yes, what is their name: Text field

Can you give a brief explaination of your legal history: Paragraph

Are you listed on any National/State Sex and/or Violent Offenders' list: Checkboxes

Check all that apply to your medical history: Checkboxes If marked other, please explain: Text field

Have you ever been diagnosed with (check all that apply): Checkboxes If any marked, please explain: Text field

Are you pregnant: Checkboxes   If yes, has pregnancy been confirmed by a Doctor: Checkboxes   If yes, what is your approximate due date: Date

Are you currently on any medications: Checkboxes   If yes, please list all medications, dosage, and why you are taking it: Paragraph

Is there any other information you would like us to know: Paragraph

 

What Speranza program are you applying for: Text field

ACKNOWLEDGEMENTS AND SIGNATURES

In completing this application and intialing the statements below, I hereby acknowledge:

Sperazna House is a spirttually-based facility and, as a result, I will be required to work a 12-step program and attend at minimum weekly church services. 

INITIALS Initials Text field

I must commit to working a highly-disciplined spirtually-based program for the next 9-12 months, once admitted to Speranza House. 

INITIALS Initials Text field

Speranza House does not permit the use of alcohol and drugs while in their program. Violation may subject me to discharge from the program and house. 

INITIALS Initials Text field

Speranza House will conduct periodic alcohol and drug screening, and that a positive result may result in immediate discharge from the program and house. 

INITIALS Initials Text field

Speranza House has my authorization to conduct a criminal background check on me, using the information I provide.

INITIALS Initials Text field

Speranza House staff may communicate on my behalf with individuals and/ or organizations who have provided treatment me in the past. This may include, but is not limited to; doctors, hospitals, and/ or other mental/health care facilities. 

INITIALS Initials Text field

I, Client first nameClient last name, acknowledge that, to the best of my knowledge I have provided true and accurate information in completing this application. Futhermore, I authorize Speranza House and any of their representives to verify validity of this information how they deem necessary. I give Speranza House staff permission to communicate with my representative, legal, or otherwise, to assist with admission to Speranza's residential, non-residential and/or Aftercare program(s). I understand that any false or misleading information could result in denial for admission, or discharge from the program.

Please Sign: Signature Today's date: Date