General Information

First Name:

Middle Name:

Last Name:

Gender:

Contact Information

Phone Number:

Email:

Details

Birthdate:

State of Birth:

Race:

Ethnicity:

Social Security #:

Are you a US Citizen?

Primary Language Spoken:

Do you have a valid Drivers License?

Do you have any driving restrictions? If so, please list them below.

Are you a Veteran?

 Branch of Service:

Type of Discharge:

Emergency Contacts

Contact #1

Family History 

What is your marital status?

Name of spouse or significant other:

Describe your relationship with your spouse or significant other:

Names and ages of any children:

Describe your relationship with your children:

Please describe your relationship with other family members:

Mother:

Father:

Step-Mother:

Step-Father:

Guardian:

Siblings:

Please describe the type of discipline used in your home:

Criminal Background & History 

How many times have you been in jail?

What dates?

List all crimes for which you have been indicted and/or convicted, and length of time served for each:

Have you ever been charged or convicted of a sex crime?

If yes, please explain:

Have you ever been charged with or convicted of domestic violence?

If yes, please explain:

Do you currently have a restraining order against you?

If yes, when does it expire?

Who file the order?

What is your relationship to them?

Have you been affiliated with any gangs?

If yes, which gangs, what was your age, and for how long were you affiliated:

Do you have any unresolved conflicts with people outside of prison?

If yes, please explain:

Are you on parole?

How long will you be on parole?

Are you on probation?

Social Support

Are you willing to have a  Be Able mentor for accountability?

If no, please explain:

Do you own a vehicle?

If you are accepted into the Be Able Housing Program, are you willing to abide by the transitional plan and complete all required program materials?

Groups

What groups or opportunities do you plan to be involved in? Please be specific.

Social Support

Please list the name and relationship of up to 4 individuals who you will utilize for a positive support system (i.e., family member, friend, pastor, mentor, etc.)

Name & Relationship: 

Name & Relationship:  

Name & Relationship:  

Name & Relationship:  

Interests

 What sports, interests and/or hobbies do you enjoy?

Finances & Employment Information

Financial Situation

Do you currently have a job?

If yes, what are the duties of your position?

How many hours do you work per week?

What is your salary or hourly pay rate?

What is the amount of your retention funds?

What is the amount of your spendable funds?

Do you have any deductions sent out?

If yes, what are the deductions?

If yes, what are the amounts?

Please list and detail the amount of all outstanding fines, fees, and payments:

Child Support:

Department of Motor Vehicles:

Restitution

Other:

What other financial support do you have?

Do you plan to apply for Supplemental Social Security Income (SSI)?

If yes, why are you applying for SSI?

Have you applied for SSI before?

If yes, when did you apply?

How do you plan to pay for fees and other financial obligations?

If you are accepted into the Be Able Housing Program, will you be committed to:

Living within your financial means?

Adhering to a budget developed by Be Able?

Ensuring that you pay rent or other obligations promptly?

Finances & Employment Information

Employment History

Are you currently employed?

Position:

Employer:

Location of employer:

Do you have physical or mental limitations that would prevent you from working?

If yes, please explain:

How will you respond when you are seeking employment and find a job, but BAHP decides the job is not in your best interest?

Education

What specific training do you have?

Apprenticeship(s)?

Spiritual Life

This section is only used to help us understand you better.
The information you provide will not be used in any determinations for your acceptance into this program.

Do you consider yourself a spiritual person?

What does spirituality mean for you?

What are some of the struggles you have in living out your beliefs?

Do you attend regular studies and/or worship services?

Do you have a “life motto” or a verse that has special meaning to you?

Medical History

Medical Conditions/Issues

Please check any that apply to you and give an explanation where applicable.

Other Medical Information

Disabilities including finger, hand, arm, leg problems, etc., including amputation:

Back Problems:

Joint Replacements:

Please describe any other medical conditions:

Please list all surgeries and the year the surgery was done:

Please list any health problems you are presently experiencing and/or any procedures you need:

Please select all known allergies:

What are your plans to meet your medical needs?

When was your last physical examination?

Medications

Please list all medications you currently take.

Mental Health & Addiction History

Mental Health

Have you ever been diagnosed with or treated for mental illness? 

If yes, what was the diagnosis?

What medications were prescribed at that time?

When did this condition begin?

Do you ever hear "voices" or have other auditory hallucinations?

If yes, when did this begin?

Do you ever have visual hallucinations? 

If yes, when did this begin?

Have you ever been diagnosed with Obsessive Compulsive Disorder (OCD) or have OCD tendencies?

If yes, please explain:

Have you ever had suicidal thoughts or attempted suicide? 

If yes, please explain:

Counseling History

Mental Health & Addiction History

Addiction History

Substances of choicePrescription OpioidsMethAlcoholDepressantsStimulantsMarijuanaBenzodiazpinesCocaineHeroinAmphetaminesHallucinogens

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(click the white box again to select more than one option)

Alcohol

Have you ever abused or been addicted to alcohol?

Beginning Age:

Type(s) of alcohol:

When was the last time you drank alcohol?

Drugs

Have you ever abused or been addicted to drugs?

Beginning Age:

Type(s) of drug:

When was the last time you used?

Other Addictions

Have you ever struggled with other types of addiction?

If yes, what type?
(check all that apply)

Recovery

What triggers cause you to resort back to addictive behaviors?
(for example: association with certain individuals/places, stress, unresolved anger, fear, etc.)

Please select all programs completed to address your addictions:

Please select any groups/meetings you currently attend:

Are you willing to participate in programs that address addictive behavior? 

If no, please explain:

Clinical Treatment History

Have you ever been to Inpatient or Outpatient Drug & Alcohol Treatment? 

If yes, please detail below:

Mental Health & Addiction History

Trauma History

Have you ever been sexually abused?

Age:

How Long?

By Whom?

Have you ever been sexually abused?

Age:

How Long?

By Whom?

Have you experienced suicide, murder, or other significant losses in your family?

If yes, please explain:

Please list any professional counseling you've had:

Acknowledgement & Submission

By signing below, I understand that the information submitted is accurate and descriptive to the best of my ability.

Name:

Signature or Initials:

Today's Date: