Apply for Admissions "*" indicates required fields Step 1 of 8 12% Referred By* Date of Admission* MM slash DD slash YYYY Completed By* DEMOGRAPHIC INFORMATIONName* First Middle Last Date of Birth* MM slash DD slash YYYY Age*Social Security Number*Phone*Email Are you a registered sex offender?* Yes No Are you a Veteran* Yes No Gender* Pronoun(s)* Sexual Orientation* Race* Ethnicity* Are you homeless?* Yes No Last Registered Address* Average Household Income* INSURANCE INFORMATIONDo you have Health Insurance* Yes No Insurance Company Name* Policy ID* Group Number* Policy Holder First / Last Name* Relationship to Resident* Employer Group* Cell #* Home #* Work #* Preferred Contact Method* SUBSTANCE USE + CO-OCCURRING DISORDER / TREATMENT HISTORYDo you need Detoxification Services?* Yes No If so, what substance(s) are you at risk of withdrawal from?* Date of Last Use* MM slash DD slash YYYY Have you received SUD and/or Mental Health Treatment before?* Yes No Inpatient Treatment History (Program / Admission + Discharge Dates)*Outpatient Treatment History (Program / Admission + Discharge Dates)*How long have you abused drugs / alcohol?* Age of first use?* Do you suffer from a co-occurring disorder?* Yes No List Diagnosed Co-Occurring Disorders*List Prescribed Medications + Prescribing Physician*Have you been to the Emergency Room within the last 30 days?* Yes No How many times have you been given Naloxone / Narcan?* Do you have a history of seizures?* Yes No Do you have any chronic medical conditions (e.g. Hepatitis C, HIV, etc.)?* Yes No List Diagnosed Chronic Medical Conditions + Treating Physician* LEGAL HISTORYHave you ever been arrested?* Yes No How many times?* Have you been convicted of a misdemeanor?* Yes No How Many?* List Dates + Charges*Have you been convicted of a felony?* Yes No How Many?* List Dates + Charges*Are you currently on probation / parole?* Yes No If YES, what were your charges and where (County / City / State)?* PROBATION / PAROLE / ATTORNEY INFORMATIONProbation / Parole Officer Name* Probation / Parole Officer Phone No.* Probation / Parole Officer Email* Attorney Name* Attorney Phone No.* Attorney Email* PRECIPITATING EVENTSWhy do you want to become a resident in the HOFFA House?Do you have other options available to you? If so, what?What do you hope to gain from your time at the HOFFA House? I have completed this form thoroughly and accurately to the best of my ability.* I agree SIGNATURE of RESIDENT Reset signature Signature locked. Reset to sign again RESIDENT PRINTED NAME Date MM slash DD slash YYYY SIGNATURE of HOFFA STAFF Reset signature Signature locked. Reset to sign again HOFFA STAFF PRINTED NAME Date MM slash DD slash YYYY Δ
