Physical Issues: Emotional Issues: Legal Issues:

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Men s Facility 1119 Ferry Street Lafayette, IN 47901 Phone: (765) 807-0009 Fax: (765) 807-0030 Hope Apartments 920 N 11th St. Lafayette, IN 47904 Phone: (765) 742-3246 Fax: (765) 269-9110 APPLICATION FOR ADMISSION Today s Date Name Date of Birth Age Gender: M F Veteran: Y N Disabilities Marital Status Race: Caucasian African American American Indian Asian/Pacific Isle Hispanic Other Current Address Phone # P.O. Box/Street Address City State Emergency Contact Relationship P.O. Box/Street Address City State Address Phone # Are You Employed? Y N Employer Highest level of education completed Do you have a picture ID? Y N Do you have previous halfway house experience? Y N If yes, where? Are you currently incarcerated? Y N If yes, what will be your release date? Physical Issues: Emotional Issues: Legal Issues:

Financial Issues: Treatment Issues: Educational Issues: Spiritual Issues: Previous experience with 12 Step programs: IDENTIFYING INFORMATION: Presenting Problem/Motivation for seeking residency: Current living arrangements: Alone Spouse/Significant other Children Parents Spouse/Significant other & children Parents & Siblings Parent & Child Other relative s Neighbor/Friend Treatment setting Shelter Halfway house Correctional Facility Homeless Other Referral: Date of last use and amount: - 2 -

SUBSTANCE USAGE: Alcohol Cannabis: -joint, blunt, bowl -hashish laced w/cocaine Cocaine -snort, smoke, inject -crack Stimulants -amphetamines, speed, crank/crystal, OTC, (Mini-thins) Sedatives Sleeping Pills Opiates Darvicet, Vicodin, Heroin, Dilaudid, Morphine, Darvon, Percodan, Demerol, Codeine, Oxycodone Tranquilizers Valium, Librium, Ativan, Xanax Hallucinogens LSD, PCP/Angel Dust, Mushrooms, Peyote Inhalants List drugs and amounts IV drug use (sharing needles) Prescribed List drugs and amounts Over the counter medications Within the last 12 months write the amount and method used: None None Rarely <1x/mo. Rarely <1x/mo. Monthly <3x/mo. Monthly <3x/mo. Weekly 1-5x/week Weekly 1-5x/week Daily 6-7x/week Daily 6-7x/week Age of first use Age of first use Other: - 3 -

LEGAL: What is your current legal status: Clear Paroled Probation Action pending Reasons/Violations/Disposition: Please list all prior criminal history: Date Charge(s) County State Disposition LETHAL BEHAVIOR: Suicide: Past ideation Current ideation Fleeting Thoughts Attempt while under the influence Attempt not under the influence Current Risk None Low Moderate High Homicidal behavior risk: None Low Moderate High Towards: Violent behavior risk: None Low Moderate High Towards: Comments: - 4 -

PHYSICAL HEALTH/IMPAREMENT: Past withdrawal Symptoms: Seizures Anxiety Sweating Hallucinations Insomnia Muscle Cramps Bone Cramps Concentration Difficulties Paranoia Depression Elevated Vitals Nausea/Vomiting Delirium Shakes/Tremors Diarrhea/Constipation Blackouts? Y N When and where? Tolerance: Increase Decrease Neither General Health: (hospitalizations, surgeries, weight loss or gain, chronic illness) Smoking: Currently If yes, Packs/day Use to Never Please list all current medications: MENTAL HEALTH HISTORY: Have you had a previous mental health diagnosis? Y N If yes, what was the diagnosis: USE HISTORY: Who introduced you to drugs/alcohol? Friend Acquaintance Significant other Spouse Siblings Other family member Self Co-worker Acquaintances Who do you use drugs/alcohol with? Alone Friends Significant other Spouse Parents Siblings Other family members Coworkers Acquaintance - 5 -

Where do you use drugs/alcohol? Street Home Workplace Bara Parties School Crack house Other Why do you think you are currently using? Cope with physical pain Relax/reduce tension Unable to stop Avoid physical withdrawal To be more social Escape reality Increase confidence Other Have you ever stopped on your own? Y N What is your longest period of abstinence in the past six months? Do you think you have a problem? Y N Why? RELAPSE INFORMATION: Have you ever experienced periods of abstinence following treatment? Y N What was the longest? Most recent relapse episodes: DATE PRECIPITATING EVENT CHEMICAL DURATION PRIOR TREATMENT: Substance abuse: Outpatient Y N When: Where: Inpatient Y N When: Where: Mental Health/Psychological Therapy: Outpatient Y N When: Where: Inpatient Y N When: Where: - 6 -

CURRENT SOCIAL HISTORY INFORMATION: Relationship status: Never married: Married Separated Divorced Widowed In relationship Is there anyone in your current living environment using drugs/alcohol? Y N Significant other Mother Father Acquaintances Spouse Sibling Friends Other family members Does/Did anyone in your family have a chemical dependency problem? Y N Mother Father Sister Brother Uncle Aunt Cousins Paternal grandparents Maternal grandparents Other family member(s) What is your employment status? Full time Part time Not employed Retired Disabled OTHER: Other: Other addictions: Shopping Sexual Eating Gambling Shoplifting Other Is there any history of physical, emotional or sexual abuse? Y N If yes, explain Will you need any assistance reading or writing while in treatment here? Y N If yes, explain Do you have any other special needs? Y N If yes, explain Comments: Family members for emergency contact: NAME RELATIONSHIP PHONE - 7 -

What would you say are your strengths that will help you in recovery? What would you say your weaknesses that will hinder your recovery? INITIAL COMMITMENT: Are you willing to attend 90 recovery oriented meeting in your first 90 DAYS? Y N Are you willing to acquire a home group and sponsor within your first 60 days? Y N Are you willing to be responsible for payment of your weekly rent for your stay? Y N Are you willing to participate in the community process during your entire stay? Y N Are you willing to follow any aftercare, probation/parole requirements if applicable? Y N If you are unemployed are you willing to actively seek employment between the hours of 9 AM and 2 PM until you have acquired gainful employment? Y N Are you willing to complete all daily and weekly chores in a timely fashion? Y N Are you willing to assist staff in duties when requested? Y N Please note that a yes or no answer to the above questions will neither qualify or disqualify you from admission to Home With Hope, Inc. All information provided on this form will be held strictly confidential in accordance with federal law. If admitted, your residency will be probationary for at least your first 60 days of your stay. During this period you will not be eligible for overnight leaves of absence, except in emergency situations with the specific approval of appropriate staff. After the 60 day probationary you will be reviewed by staff and if approved will be given permanent resident status. I hereby agree that the above provided information is accurate, complete and truthful, to the best of my knowledge: Applicant Signature: Date: Staff Approval: Date: - 8 -

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