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 RESIDENTRESIDENT PRINTED NAME Date MM slash DD slash YYYY SIGNATURE of HOFFA STAFFHOFFA STAFF PRINTED NAME Date MM slash DD slash YYYY Δ
