Application for Admission

Getting Started
Date:
First: Middle: Last:
SSN: DOC:
DOB: Age: Sex: M   F
Referring Agency:
Referring Agency Address:
Referring Person:
Referring Person's Phone: Fax:
Email:
Drug History
Have you been to other treatment facilities:   Yes   No
If yes, where and when:
Drug of Choice Age When first used:
Frequency of Use Method of Ingestion
Second Drug of Choice Age When first used:
Frequency of Use Method of Ingestion
Third Drug of Choice Age When first used:
Frequency of Use Method of Ingestion
Medical Insurance
Do you have medical insurance:   Yes   No
What Company
Policy Holder's Name:
Policy No: Group No:
Telephone:
Type of Coverage:   PPO   HMO   Other
Explain:
Medical History
Do you have any present medical conditions:   Yes   No
If yes, please list:
Do you have any past medical conditions:   Yes   No
If yes, please list:
If female, date of last pregnancy test: Result of last test:
Are you disabled?   Yes   No
Any physical limitations?
Psychiatric History
Do you have a past or present psychiatric diagnosis?   Yes   No
Where and when were you diagnosed:   
What was the diagnosis?   
Medications
Are you currently taking any medications:   Yes   No
Name of Drug: Dosage
Name of Drug: Dosage
Name of Drug: Dosage
Name of Drug: Dosage
Military History
Are you a veteran?   Yes   No
If Yes, Which branch did you serve in?   
Date:   From     to:   
What type of discharge?   
Employment History
Place of last employment:     Date:
Type of Work Experience:   
Income Status
Do you receive an income:   Yes   No
If yes, which kind:   SSI   SSDI   Unemployment   Wages
Other      Monthly Income:
Do you have any financial responsibilities:   Yes   No
What are they?
Legal History
Any present legal issues?   Yes   No
If yes, list charges, dates, and locations:
Any past legal issues?   Yes   No
If yes, list charges, dates, and locations:
Have you been in prison?   Yes   No
If yes, list when and where:
Release Date(s):   DOC No:
Are you currently on parole, probation, or community service?   Yes   No
Explain:
Probation Officer's Name:  
Address:   
Telephone No:     Cell No:   
Education
Highest Grade Completed      Do you have a GED?   Yes   No
If you have a college degree, list degree:  
Field of Study:   
Marital Status
Single   Married   Widowed   Divorced   Seperated
Do you have children?   Yes   No
    If yes, how many?      Ages:   
    Whom do they reside with?  
    (Example, Mother, Father, Aunt, Grandmother, other, etc)
    Where they reside   
Do you have parental rights?   Yes   No
Living Arrangements
Are you homeless?   Yes   No     If yes, how many times?      For how long?  
If not, what is your current address?
City     State     Zip
Telephone:     Cell:
Person to Contact in Case of Emergency
Name:
Relationship:
Address:
City     State     Zip
Telephone:     Cell:
Your Goals and Plans
What do you hope to accomplish if admitted to The Transition House?
What are your short term goals?
What are your long term goals?
What is your plan to obtain employment?
What are your plans to obtain long term permanent housing?