SPERANZA HOUSE PROGRAMMING APPLICATION

RESIDENTIAL/ NON-RESIDENTIAL SERVICES

Today's Date:

Client's Name:

Date of Birth:

   Social Security #: 

Height: 

        Weight: 

Email: 

   Phone #: 

Address: 

City: 

   State:    Zip: 

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

Current Relationship Status: 

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: 

   Ages:    Do you have a current DCS case: 

If yes, please give a brief explanation: 

DCS Caseworker Name/Agency/Phone Number: 

What is your highest level of education: 

Date of last substance use: 

   What is your drug(s) of choice:    If marked Other: 

Do you have a valid Driver's License: 

   What is your DLN: 

Do you have any physical or learning disabilites: 

   If yes, please explain: 

Were you referred to Speranza House: 

   If yes, who referred you: 

Why are you motivated to be in our program: 

Are you eligible for Recovery Works Funding: 

Are you currently incarcerated: 

   If yes, what facility: 

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

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

Do you have any felony convictions: 

   If yes, felony(s) level: 

County(s)/State(s) of conviction(s): 

Are you currently on (check all that apply): 

   If marked other, please explain: 

County(s) of Placement: 

   Name of Officer(s): 

Do you have a history of DOC Incarceration: 

   If yes, in what facility(s):   

Do you have a pending criminal charge(s): 

   County(s) of pending charge(s): 

 

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

Do you have an attorney: 

   If yes, what is their name: 

Can you give a brief explaination of your legal history: 

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

Check all that apply to your medical history: 

 If marked other, please explain: 

Have you ever been diagnosed with (check all that apply): 

 If any marked, please explain: 

Are you pregnant: 

   If yes, has pregnancy been confirmed by a Doctor:    If yes, what is your approximate due date: 

Are you currently on any medications: 

   If yes, please list all medications, dosage, and why you are taking it: 

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

 

What Speranza program are you applying for: 

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 

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

INITIALS 

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 

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 

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

INITIALS 

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 

I, 

, 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:

Today's date: