Official PH Intake eval.

Who is Filling out this Form

First NameLast Name

Student Name

First NameMiddle NameLast Name

Birth Date

MonthDayYear

Gender

Social Security Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What hometown are you originally from?

Mobile Number

Format: (000) 000-0000.

Phone Number

Format: (000) 000-0000.

Work Number

Format: (000) 000-0000.

Which location are you interested in ?

How did you hear about us?

What identification do you have?

What is your sexual orientation ?

Are you..

How many children do you have?

Do you have

Are you willing to comply with the hair and shaving policy?

Do you have

If so what

Do you have

If yes, please provide the location and charges.

Have you ever been convicted of a sex crime?

What are you currently using or struggling with?

When was the last time you used?

How long have you been using continuously?

Are you in need of detox first?

Are you currently using nicotine products?

Do you have medical insurance?

If yes what is it

Do you have any of these medical conditions

Please explain if any

Please list any other medical conditions that may affect your participation.

Do you have any allergies?

Other

If yes, please specify your allergies.

How many times a day do you take medication?

Have you been ever diagnosed with any of the following

Have you ever been suicidal?

If yes, please explain the circumstances.

Please list any and all medications you are taking, including prescription and over-the-counter medications. Include the name, dosage, and frequency.

According to the Chart above At the time of Admission will you be under the Federal Poverty Level

Are you able to obtain a 90-day supply of medications before your entry date?

Are you currently receiving any of the following mental health payments?

Other

If yes, please state what you receive and the amount.

Project Hope/Saving Grace requests a one-time, non-refundable induction fee of $1,000.00. Please indicate how your payment will be made below:

**Induction Fee Disclosure** If full or partial induction fee payment(s) are made during the duration of the program, the amount paid will be refunded to the paying party upon successful completion of the program. Do you understand the parameter of this disclosure? Do you understand this induction fee disclosure?

**Travel Expense Disclosure** If full or partial induction fee payment(s) are made during the duration of the program, a portion of the induction fee will be allocated for travel expenses if an individual enrolled in the program is dismissed for violating the program’s policies and procedures or chooses to leave against ministerial counsel. Do you understand the parameter of this disclosure? Do you understand this travel expense disclosure?

**Non-payment Disclosure** If full or partial induction fee payment(s) are not made during the duration of the program, Project Hope/Saving Grace is not obligated to and will not provide travel expenses if an individual enrolled in the program is dismissed for violating the program’s policies and procedures or chooses to leave against ministerial counsel. Do you understand the parameter of this disclosure?Do you understand this non-payment disclosure?

**Medical 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. Do you understand this medical disclosure?

Please provide an email address or cell phone number where the program rules can be sent.

Personal Notes Post Interview

Please Type Clients Email Use This Example. If the email is John@Gmail.com please type it in the box as John AT Gmail DOT COM. If THEY do not have an email then please get an email of one of their family members THIS IS NEEDED

Mens Admissions

Legal Questions

Drug / Alcohol History

Medical / Mental History

Mental Health MHMR