Homes of Hope Application

Transcription

1 Homes of Hope Application Name: DOB: date: Address: City: State: Zip code: SS# Phone number: Primary language: Secondary language: Ethnicity: Religion preference: Single: Married: Divorced: Do you have insurance? yes If so, name of insurance: policy number: Are you receiving support from other organizations? yes If so, please list the organizations: Do you have a driver s license? yes license number: Do you have a car? yes Vehicle information: Type: make: model: Color: Emergency Contacts: Are they aware you are in the program yes Name: license plate: relationship: Address: Phone number: Name: relationship: Address: Phone number: 1

2 Children: Are you currently pregnant? yes no Do you have children? yes Are the children currently in your custody? yes no if so due when: Are social services involved with you and your children? yes If so, who is the Social Worker in the case? Address: Phone number: FATHER OF UNBORN CHILD: Name: Address: Phone: Intent: Marriage: yes _ Adoption: yes Uncertain Child Support: yes _ Please list your children: Name: DOB: ages: Prenatal Care: yes Physician Tel # Address: Do you have Medicaid? yes _ Do you have TANF? yes Do you have Food stamps? yes INCOME ACKNOWLEDGEMENT This is to certify that my/our total income is $ This is to certify that I receive in TANF This is to certify that I receive in FOOD STAMPS This is to certify that I receive in WIC This is to certify that I receive. Please list any other monies or benefit that is not listed above. 2

3 Do you have child care? yes Education: High school graduated from: Do you have a GED: yes Are you currently attending college? yes year: College attended: year completed: Please list certifications: Did you have problems in school? yes If so, please explain: Work History: Employer: address: start date: end date: Are you currently working? yes If so, please where? phone number: Criminal History: Are you willing for a background check to be completed? yes Have you ever been convicted of a crime? yes when? If so, please explain Felony? yes when? If so, please explain Misdemeanor? yes when? If so, please explain 3

4 Child abuse? yes Elder abuse? yes Medical History: child neglect? yes elder neglect? yes Last physical exam: Last OB/GYN exam: Who is your family doctor: phone number: Who is your OB/GYN: phone number: Other specialist: phone number: Other specialist: phone number: List of medical history: List of surgeries and when: List of hospitalizations and when: Do you have vision problems: yes Do you have hearing problems: yes Last menstrual cycle: Have you been allergy tested? yes List of allergies: glasses/contacts: yes hearing aids: yes when: Do you have an epi-pen? yes Do you have an inhaler? yes no List of mental health history: 4

5 Last psych exam: by whom: Are you seeing a counselor: yes If so, who: phone number: Please check the following immunizations you have received and write the date received: Hepatitis A Hepatitis B DTAP HIB polio MMR Varicella HPV influenza pneumococcal meningococcal Have you been tested for STD s yes Have you had an STD? yes Do you currently have an STD? yes no If so, Please explain Have you partaken of alcohol in the past? yes no Are you currently drinking? yes Have you partaken of illegal substances in the past? yes no Are you currently using illicit drugs? yes Have you taken prescription narcotics in the past? yes Are you currently taking prescription narcotics? yes History of abuse: physical sexual n/a Have you attempted to commit suicide in the past? yes no Are you currently suicidal yes If so, do you have a plan? yes when was your last drink? When was the last time? The last time? when: If so, what is your plan? 5

6 Medications: Are you currently taking any medications? yes Are you on birth control? yes What form: If so please list the medications (vitamins, OTC, prescription) Name Dose How often What for Any other information we should know about? Any questions? LEGAL HISTORY/ INCARCERATION (please list dates and charges) 6 6

7 DRUG FREQUENCY TREATMENT FIRST USE SOB/CLEAN MARIJUANA COCAINE AMPHETAMINES/METH PERSCRIPTION OTHER (LIST) ALCOHOL Have you been or are you currently attending a drug treatment program? yes _ Are you receptive to drug and alcohol treatment if necessary? yes If you answered no, why? POLICY: DRUG TESTING Description: PHFS/ Homes of Hope has a policy against the use of alcohol, illicit drugs, and/or misuse of prescription medications. Procedure: 1. All applicants are required to take an initial UA, failure to pass this test requires Outpatient treatment. 2. If at any time it is suspected that you are abusing substances, you may be asked to drug test and must release the results of that test to PHFS. 3. If you refuse to do so, you may be asked to leave the Host Home. 4. If you do test positive, every effort will be made to assist you in the receiving the appropriate rehabilitative services. Client Date 7

8 RELEASE OF INFORMATION I, AUTHORIZE Patrick Henry Family Services, To contact For the release of any or all; social, medical, and psychological information concerning myself, which might be pertinent to my progress during my stay at Home of Hope. Client: Date: 8

9 Probation Period Agreement (Sixty-day period) From this day, through (Date of Entry) (End of Two Week Period) I, agree to uphold the conditions of this agreement as stated below. I will complete all intake paperwork. I will follow all house rules and expectations. I acknowledge and understand that during this time there are no outings except for doctor appointment, Medicaid, WIC or food stamps or other pertinent appointments. These appointments will need to be approved. I will understand Homes of Home staff will be evaluating my readiness for the program. I will decide if I want to stay at Homes of Hope and fully participate in the program. If I decide not to participate in the Homes of Hope program, I will make arrangements to leave within 24 hours. At the end of my probation period I will abide with the decision made by the staff in regards to my residency at Homes of Home. Signed by: Recommendations for residency: For Staff Use Only: Date: Home of Hope Supervisor: Date: Director: Date: 9