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ADMISSION APPLICATION                                                                      DATE:_______________________

 

NAME:___________________________________________________________________________________

           FIRST                                                 MIDDLE                                                              LAST

SOCIAL SECURITY NUMBER: _____________-___________-_____________

DRIVERS LICENSE OR STATE ISSUED ID:_______________________________________________-

AGE:_______DATE OF BIRTH:_________________STATE OF BIRTH:_________________________

CURRENT ADDRESS: (STREET, CITY, ZIP)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

CONTACT PHONE:___________________________________SECONDARY CONTACT NUMBER:________________________

ARE YOU CURRENTLY IN DRUG COURT:____________Y  ________________N IF YES, WHAT COUNTY:__________________

MARITAL STATUS: __________SINGLE ____________MARRIED__________ DIVORCED___________WIDOWED___________

DO YOU HAVE CHILDREN:_______Y _______N IF SO WHAT AGES:________________WHOM DO THEY LIVE WITH:________

DO YOU HAVE PARENTAL RIGHTS: ________Y _________N

WILL YOUR FAMILY PARTICIPATE IN YOUR RECOVERY? _________Y ________N

NAME AND CONTACT NUMBER IN CASE OF AN EMERGENCY: ________________________________________

WHAT IS THE HIGHEST LEVEL OF EDUCATION YOU HAVE COMPLETED? ____________________

DO YOU HAVE PROBLEMS WITH READING AND/OR WRITING? __________Y ____________N

PLEASE LIST 3 PREVIOUS EMPLOYERS STARTING WITH MOST CURRENT FIRST:

COMPANY NAME                           SUPERVISOR                       ADDRESS                         PHONE NUMBER

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

DO YOU HAVE ANY SPECIAL WORK EXPERIENCE AND/OR SKILLS? ___________Y ______________N

IF YES, PLEASE LIST: ________________________________________________________________________________________________________________________________________________________________________________________________________________

ARE YOU CURRENTLY RECEIVING SSI AND/OR DISABILITY BENEFITS: _____________Y ____________N

ARE YOU CURRENTLY RECEIVING SNAP BENEFITS/FOOD STAMPS: _______________Y ______________N

DO YOU HAVE A HISTORY OF SUBSTANCE ABUSE AND/OR ADDICTION: _____________Y ____________N

SUBSTANCE USED         AGE OF FIRST USE       DATE LAST USED      HOW MUCH/HOW OFTEN

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

LAST TIME YOU USED:_________________________ IV USER: ________________Y _________________N

DO YOU HAVE A HISTORY OF WITHDRAWALS: _____________________Y _________________N

HAVE YOU BEEN TO A TREATMENT FACILITY (RESIDENTIAL AND/OR OUTPATIENT ______________Y ___________N

IF YES, LIST NAME OF FACILITY AND DATES ATTENDED:______________________________________________________________________________________________

PLEASE LIST ALL LEGAL CHARGES WITH CURRENT FIRST:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HAVE YOU RECEIVED A DWI/DUI:_______________Y ____________N IF SO, WHEN AND HOW MANY?___________________

HAVE YOU EVER BEEN CONVICTED OF A VIOLENT CRIME: __________Y ___________N

ARE YOU A REGISTERED SEX OFFENDER: __________Y ___________N

DO YOU HAVE ANY PENDING COURT DATES: _________Y _________N

IF SO PLEASE LIST BELOW:

LOCATION                                 DATE & TIME                               CHARGE                                  JUDGE

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

DO YOU HAVE OUTSTANDING WARRANTS: _______________Y ________________N IF SO, PLEASE LIST BELOW

CITY                                                                    COUNTY                                                              STATE

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

DO YOU HAVE AN ATTORNEY: ________________Y _______________N IF SO: PLEASE LIST NAME AND PHONE NUMBER

________________________________________________________________________________________________________

ARE YOU ON PROBATION AND/OR PAROLE: __________Y ____________N IF YES, PLEASE LIST BELOW OFFICERS NAME COUNTY AND PHONE NUMBER

________________________________________________________________________________________________________

HAS TRANSFER FROM YOUR COUNTY BEEN APPROVED BY YOUR OFFICER: ____________Y ___________N

DO YOU HAVE ANY FOOD/MEDICAL ALLERGIES: ___________Y _____________N IF SO, PLEASE LIST BELOW

________________________________________________________________________________________________________________________________________________________________________________________________________________

DO YOU HAVE ANY MEDICAL CONDITIONS (past or present): ______________Y _________________N IF YES, PLEASE LIST 

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HAVE YOU EVER BEEN DIAGNOSED WITH A MENTAL HEALTH DISORDER: ________Y _______N IF SO, PLEASE LIST

________________________________________________________________________________________________________________________________________________________________________________________________________________

ARE YOU RECEIVING ANY TYPE OF COUNSELING SERVICES AND/OR CARE:________Y ________N

PLEASE LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING:

MEDICATION & MG                     HOW OFTEN                  REASON FOR TAKING        WILL YOU BE BRINGING WITH YOU

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HAVE YOU EVER BEEN DIAGNOSED WITH TB: ________Y ________N IF SO, ARE YOU CURRENTLY TAKING MEDICATION FOR TREATMENT AND/OR PREVENTION OF TB:________Y ________N

HAVE YOU EVER BEEN DIAGNOSED WITH AN EATING DISORDER:_________Y _________N

HAVE YOU EVER ATTEMPTED AND/OR HAD THOUGHTS OF HURTING YOURSELF: ___________Y ________________N

DO YOU HAVE MEDICAL INSURANCE:________________Y ________________N

 

PLEASE READ AND INITIAL THE FOLLOWING STATEMENTS IF YOU AGREE TO THAT STATEMENT

* I understand and agree to NOT take medications which are of a narcotic (controlled substance) nature/class while in the HOPE ALIVE program. I understand that I am here on a voluntary basis, and if I feel like I need medication I will inform staff of my situation, and they will then make arrangements to get me to a facility where medications and care can be given from trained medical professionals. I agree that I am making this agreement on my own accord, and am NOT being forced in any way to stop taking prescribed medications. _____

* I understand and agree that HOPE ALIVE is a faith-based transformational program and I will be required to work five days a week, attend all classes, services, and events as designated by staff and comply with the rules and regulations specified by HOPE ALIVE and understand that failing to do so can result in eviction and termination from the program. ______

* I certify that the information in this application is true and correct to the best of my knowledge and belief. And that if I am accepted as a resident, I give HOPE ALIVE permission to speak freely with all legal entities I have cases through and agree to a criminal background check; search of personal property and possessions at any time with or without notice; random drug testing in which positive results can be cause for immediate eviction and I understand that use and/or possession of drugs and/or alcohol, disruptive behavior, can and will cause immediate eviction without recourse. _______

* I understand also that my information/photo/etc. may be used to help promote the cause and purpose of HOPE ALIVE MINISTRIES._______

* I hereby authorize HOPE ALIVE and its designated agents and representatives to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for employment and/or volunteer purposes. I understand that the scope of the consumer report/investigative consumer report may include, but is not limited to the following areas: verification of social security number; credit reports; current and previous residences; employment history; education background; character reference; drug testing; civil and criminal history records; etc. _____

PLEASE SIGN ONLY IF YOU AGREE TO ALL OF THE ABOVE STATEMENTS

______________________________-                  DATE:____________________________________-

APPLICANTS SIGNATURE