Official PH Intake eval

Project Hope Mens Admissions

Fill out the form carefully for registration
Who is Filling out this Form *

First Name Last Name
Student Name

First Name Middle Name Last Name
Birth Date *

Month Day Year
Gender
Social Security Number *
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
What hometown are you originally from?
E-mail
example@example.com
Mobile Number
Phone Number
Work Number
Which location are you interested in ?
How did you hear about us?
Do you have

Drivers License State ID No ID
What is your sexual orientation ?

Straight Gay Bisexual
Are you..

Single Married Divorced Separated
How many children do you have?
Can you Read and write?

Yes No
Legal Questions
Do you have any pending court dates?
If so Please give information
Are you currently on probation or parole?
Probation officer name
Location
Phone number
Email
Have you ever been convicted of a sex crime
Drug / Alcohol History
What are you currently using and or struggling with?
When was the last time you used?
How long have you been consecutively using for?
Are you in need of a detox first
Are you currently using any nicotine products
Medical / Mental History
Do you have medical insurance?
If yes what is it
Do you have any of these medical conditions

Hepatitis HIV / AIDS STD's TB Asthma High Blood Pressure Diabetes Epilipsy / Seizures Other
Please explain if any
Any other medical conditions not listed that we need to be made aware of that may hinder you from working while in the program
Any Allergies

Food Medecine Other
If so what
Mental Health MHMR
Have you been ever diagnosed with any of the following

Depression Anxiety PTSD Bipolar Schizophernia / Hearing Voices Eating Disorder Cutting or Self Harm Other
Have you ever been suicidal
If so please explain the circumstance
Please list any an all meds that you are taking. These include prescription and over the counter meds
You are required to have a 90 day supply of meds upon admission. Are you able to obtain these before your entry date

Yes No Not Sure
Are you currently receiving any of the following

Unemployment Social Security Food Stamps 401k Other
If yes then what and how much
We ask for a one-time non-refundable $1000 induction fee. Will you or your family be able to make a full payment? or make several payments

Full 1000 2 x $500 3 x $333 Payment Plan
Disclosure We are NOT a Medical Facility If you are due for a doctors checkup or are in need of dental work, we strongly advise that you take care of that before you entering our program. YOU WILL NOT see a doctor for at least 90 days unless it is an emergency. The only meds that you are allowed to bring are the meds we have talked about in this interview. If you claim to need a medication that you did not mention in your interview you will not be allowed to get that medication. Expect Discomfort once your body is clean and sober you will feel pain that your DOC was numbing. After going over this interview are there any further questions that you have for me at this time? The interview is now completed If you are interested in coming to our program i will email you to Read the Rules of the Program and sign them before arriving. Do you understand everything that we have talked about today and what is involved.

Yes No
The interview is now completed If you are interested in coming to our program i will need you to Read the Rules of the Program and sign them before arriving. Please Provide a Email address or Cell Phone Number Where they can be sent to you.
Personal Notes Post Interview
Should be Empty:

Project Hope Mens Admissions

Legal Questions

Drug / Alcohol History

Medical / Mental History

Mental Health MHMR