Valley Rescue Mission Women & Children's Center
Application for Consideration of Admission. 1200 11th Avenue Columbus, Georgia 31901 706-507-4314 Fax: 706-507-4303
Name
*
First Name
Last Name
Age
*
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
-
Area Code
Phone Number
Email
example@example.com
Height:
Weight:
Hair:
Eyes:
Client
Referred By:
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Why are you applying to a rehabilitation program at this time?
*
What are your immediate needs?
*
What are your present goals?
*
What are your strengths?
*
What are your weaknesses?
*
Do you have children of who will be staying with you at this time?
*
YES
NO
Have you ever been convicted/arrested of a violent/sexual crime
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YES
NO
Have you ever been diagnosed with a mental illness?
*
YES
NO
Are you currently taking any medications?
*
YES
NO
Were medications prescribed?
*
Yes
No
Medications (if any)
Reason for taking
Frequency
Date of next refill
Medication Name
Medication Name
Medication Name
Medication Name
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Family Information
Name
Age
Date of Birth
Child
Child
Child
Child
Child
Child
Child
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone
*
-
Area Code
Phone Number
Emergency Contact Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Do you have family in Muscogee County or the immediate area?
*
Yes
No
Please list family outside of Muscogee County or immediate area
Name
Relationship
Supportive?
Name:
Name:
Name:
Is there any further information you can offer which might help us in determining your admission?
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Alcohol/Drug History
Amount/How often used
Date Started
Date of last use
Cocaine/Crack
Marijuana
Heroin
Alcohol
Nicotine
Prescription Drugs
Methamphetamines
Other
Age at first use:
Longest period of sobriety:
Drug of Choice:
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Have you ever attempted suicide?
*
Yes
No
If yes, how many times?
Date
Circumstances
Treatment
Date
Attempt
Attempt
Do you have current suicidal thoughts
*
Yes
No
If yes, please describe
Hospitalized for emotional or nervous reasons?
*
Yes
No
Have you ever been in therapy?
*
Yes
No
Mental Health Treatment
Date
Chief Complaint
Therapist Name
Type of Therapy
Name of Facility
Name of Facility
If yes, please describe
Please describe any family or self-psychiatric history:
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Abuse History - Have you ever experienced any of the following types of abuse?
Childhood
Adult
Physical Abuse:
Emotional or Verbal Abuse
Sexual Abuse
Are you presently in contact with anyone who is/was abusive to you?
*
Yes
No
If yes, please describe
Legal History
Have you ever been arrested
*
Yes
No
If yes, please describe
Are there any pending charges?
*
Yes
No
Are you on probation/parole?
*
Yes
No
Address
Phone Number
Probation/Parole Officer Name
Probation/Parole Officer Name
Medical History
Are you currently under medical supervision?
*
YES
NO
Physician Information
Name
Address
Phone
Date of last physical
Physician
Physician
Have you ever had any of the following?
*
Seizers
Heart Disease
Respiratory Problems
Diabetes
Hepatitis
Venereal Disease
Vision Problems
Tuberculosis
Hearing Problems
Other
N/A
If you checked any of the above, please explain:
Are there any medications you should be taking?
*
YES
NO
If yes, please explain:
Have you had any major/minor surgery in the last five years?
*
YES
NO
If yes, please explain:
Is there any chance that you could be pregnant?
*
YES
NO
If yes, please explain, how many months and complications:
Have you ever had an abortion?
*
YES
NO
If yes, how many?
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Educational/Vocational History
What is your education background:
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High School
GED
Some College
College Graduate
Technical College
Are you a Veteran?
*
YES
NO
If yes, Branch of Service / Discharge Date / Type of Discharge
Last employer / date / location:
Still employed?
*
YES
NO
Housing / Credit History
Last Residence
Reason vacated:
Ever received housing assistance:
*
YES
NO
if yes, please explain / from whom:
Do you owe the housing authority money?
*
YES
NO
Are you presently homeless?
*
YES
NO
Do you have any outstanding debts? (Loans, credit cards, bills, etc.)
*
YES
NO
Are you currently receiving medicare, medicaid, disability or other government aid?
*
YES
NO
if yes, please explain / from whom / amount:
An important part of this program is community service. Every member of this Program participates in community involvement and operation of all residential Duties. If selected for residence in this program, is there anything we should know about you that would hinder your ability to sweep, mop, lift, mow, or do normal household chores?
*
YES
NO
if yes, please explain / from whom / amount:
Please give a little background about yourself and why you feel this is the right program for you.
*
Signature
*
On mobile device, use finger or stylus to sign. On Pc/laptop, use mouse to sign.
Signed Name
*
First Name
Last Name
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