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.
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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