Applicant Information
Client first name Client middle name Client last name
Client AddressClient CityClient StateClient StateClient Zip
Do you plan to on returning to the above address following the completion of this program? Text field
If you go on over night passses is this where you plan on going? Text field
Home PhoneText field Cell PhoneText field
Email Address Text field Social Security NumberText field
Date of Birth Text field Marital Status Text field Number of Children Text field
Childrens names/ages
Text field
Text field
Spouse/Partner NameText field Contact NumberText field
Address Text field
CityText field State Text field Zip code Text field
Email Text field Home Phone Text field Contact Text field Release of Information for that person? Text field
Contact Name Text field Relationship Text field
Address Text field
City Text field State Text field Zip Text field
Home Phone Text field Cell Phone Text field
Legal Information-Are you legally mandated to be here? Text field Legal Charge? Text field
On Probation? Text field On Parole? Text field Outstanding Warrants? Text field
Have you ever been convicted of any violent crime? Text fieldSexual Crime? Text field
Supervision/Probation or Parole Officer Name Text field
Address Text field
City Text field State Text field Zip Code Text field
Contact number Text field Fax Text field
Has release of information been signed? Text field
Do you want or need us to report your progress to your parole or probation officer? Text field
Demographic Information MaleText field FemaleText field
Race? Text field Caucasian Text fieldAfrican American Text fieldNative American Text fieldAsian Pacific Isander Text field Hispanic Text fieldOther
Education Background Text fieldLess than high school Text fieldHS/GED Text fieldSome College Text field2-year degree Text field4-year degree Text fieldMasters or PHD
Professional Licenses(MD, DWM, etc.) Text field
Are you employed? YText field NText field
Current Employer Text field
Employer Address Text field
City Text field StateText field PhoneText field
Current work schedule
MondayText field TuesdayText field WednesdayText field ThursdayText field FridayText field SaturdayText field SundayText field
Household income (select one)
Text fieldLess than $10,000 Text field $10,000-$25,000 Text field$25,000-$50,000 Text field$50,000-$75,000 Text fieldOver $75,000
Religious Preference Text fieldProtestant/Christian Text fieldCatholicText fieldJewishText fieldOtherText fieldNone
Are you receiving public assistance or other non-job related income? Text fieldYText fieldN
What is your monthly income?Text field
Do you have valid I.D.>Text fieldYText fieldN
Do you have a valid drivers license? YText fieldNText field
Do you have a car? YText fieldNText field If yes is it registered and insured? YText fieldNText field
Make/ModelText fieldLicense plate numberText field
Military ServiceText fieldYText fieldN BranchText field Type of dischargeText field
Substance Use HistoryText field Current Sobriety DateText field
Drug of ChoiceText field
How did you use?Text field How Often?Text field
Have you ever relapsed? YText field NText field If yes, how many times?Text field
Age of first use?Text field
Referral Information
Have you ever been to a treatment center?Text field How many time?Text field
Last treatment center name?Text field
Case managers nameText field Has release of information been signed?Text field
Who referred you to FHA?Text field
Please answer the following questions, check all that apply:
1. Who suggested you come here?Text field
Text fieldFriend or Family Text fieldEmployer/Co-worker Text fieldTreatment or Human Services Professional Text fieldRepresentitive of courts/Judical System Text fieldNone Text fieldOther
2. How long have you been using drugs/alcohol?Text field
3, In the past 30 days where have you been living most of the time?Paragraph
4. Are you currently enrolled in school or a job training program?Text field
5. Are you disabled/unable to work?Text field
if so please explainParagraph
6. In the past 30 days have you attended any self-help or recovery programs?Text field
if so, please explainParagraphhow manyText field
7. What type of 12 step groups do you prefer (AA/NA,etc.)?Text field
8. Do you have a sponsor?Text field If you do, do you have a home group?Text field
9. How would you rate you quality of life? Text fieldVery poor Text fieldPoor Text fieldNeither poor nor goodText fieldGood Text fieldVery Good
10. What would you like to accomplish while you are at HFA?Paragraph
11. What are your three main goals, and why are they important to you?Paragraph
12. What potential challenges do you see in improving your recovery?Paragraph
13. What would be helpful for us to know about you to best serve you while you are at FHA?Paragraph
14. Are you having a mental health crisis today or do you feel that you need to see a behavioral health professional? If yes, please explain:Paragraph
Are you on a maintence program?Text fieldYText fieldN if yers please list:
1.Text field
2.Text field
3.Text field
4.Text field
5.Text field
Do you have any serioius medical conditions or allergies? Text fieldYText fieldN if yes, please list
1.Text field
2.Text field
3.Text field
4.Text field
5.
The information i have provided on this application form is true and correct to the best of my knowledge.
I authorize the verification of the information on this application as to my legal and employment.
Applicant Printed NameText field
Applicant SignatureSignature
Date of ApplicationText field
STAFF ONLY
Prescreening phone interview completedText field
WaitlistedText field
ApprovedText field
DeniedText field
Staff Signature Signature