Damascus House for Women Application
Please fill out every field and ensure you sign all the proper fields
Name
*
First Name
Last Name
Middle Initial
*
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Home Phone Number (if applicable)
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Driver's License Number
*
Is your driver's license suspended?
*
Yes
No
Explain:
*
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Weight
*
Height
*
Hair Color
*
Eye Color
*
Marital Status
*
Please Select
Single
Dating
Engaged
Married
Separated
Divorced
Serious Relationship
Lesbian/Transgender
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MARRIAGE AND FAMILY INFORMATION
Name of Spouse/Significant Other
*
First Name
Last Name
Spouse/Significant Other Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Spouse's/Significant Other Occupation
*
Spouse's/Significant Other Age
*
Do you have children?
*
Yes
No
INFORMATION ABOUT CHILDREN
Please fill in all fields for each of your children
*
Rows
Name
Age
DOB
Male/Female
Custody
Child 1
Child 2
Child 3
Child 4
What arrangements are being made for your children while you are at The Damascus House for Women?
*
Education (last year completed):
*
Other training (list the type and years completed):
*
Who referred you to The Damascus House For Women?
*
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HEALTH INFORMATION
Rate your health:
Very Good
Good
Average
Declining
Other
Explain
*
Weight Changes:
Lost
Gained
Neither
Do you consider your eating habits normal?
*
Yes
No
Explain
*
Are you on a special diet?
*
Yes
No
Explain
*
Do you have any medically verifiable food allergies?
*
Yes
No
Explain
*
Do you have any medically verifiable disabilities?
*
Yes
No
Explain
*
Date of last medical examination:
*
List an physical limitation you may have as indicated by a physician
*
Have you had any past surgeries or medical hospitalizations?
*
Yes
No
List all past surgeries or medical hospitalizations including reason and date:
*
Do you take any prescription medications?
*
Yes
No
Prescription History
*
Rows
Name
Dosage
For What Reason
How long
Prescription 1
Prescription 2
Prescription 3
Prescription 4
Prescription 5
Prescription 6
Prescription 7
Prescription 8
Preferred Drugs (including Nicotine products):
*
Rows
Name of Drug
Frequency of Use
Date of Last Use
Drug Name
Drug Name
Drug Name
Drug Name
Drug Name
Drug Name
Drug Name
Have you ever experienced a life-altering, traumatic event, that still affects you?
*
Yes
No
Explain
*
Have you recently suffered the loss of someone close to you?
*
Yes
No
Explain
*
Have you ever been tested for an STD, HEP-C, HIV/AIDS?
*
Yes
No
Please provide month and year of when you were tested
*
What was the result of your STD, HEP-C, HIV/AIDS test?
*
Are you currently pregnant?
*
Yes
No
Do you have any learning disabilities (reading or writing)?
*
Yes
No
Explain
*
SPIRITUAL BACKGROUND
Do you believe in God?
*
Yes
No
Uncertain
Are you saved?
*
Yes
No
Not sure what you mean
PERSONALITY INFORMATION
Have you ever had any psychotherapy or counseling before?
*
Yes
No
Exlpain
*
If yes, list counselor or therapist and dates you were in counseling:
*
What was the outcome?
*
Have you ever been in a drug or alcohol program?
*
Yes
No
Recovery Program History
*
Rows
Date of Entry
Program Name
City/State
Reason for Leaving
Date of Discharge
Facility 1
Facility 2
Facility 3
Facility 4
CHECK ANY OF THE FOLLOWING WORDS WHICH BEST DESCRIBE YOU NOW:
*
Active
Ambitious
Self-confident
Persistent
Nervous
Hardworking
Impatient
Impulsive
Calm
Moody
Often-blue
Excitable
Imaginative
Serious
Easy-going
Shy
Good natured
Introvert
Extrovert
Likeable
Leader
Quiet
Submissive
Lonely
Self-Conscience
Sensitive
Have you ever felt like people were watching you?
*
Yes
No
Explain
*
Have you ever had hallucinations?
*
Yes
No
Explain
*
Are you afraid of being in a car?
*
Yes
No
Explain
Do you have problems sleeping?
*
Yes
No
Explain
Have you ever tried to commit suicide?
*
Yes
No
Why?
Have you ever received psychiatric care or been in a psychiatric hospital?
*
Yes
No
Psychiatric Hospitalization History
*
Rows
Date of Entry
Program Name
City/State
Reason for Leaving
Date of Discharge
Facility
1
Facility 2
Facility 3
Facility 4
Are you on any type of government or financial assistance, such as Welfare, SNAP or SSI?
*
Yes
No
What type?
*
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Additional Information
1. Describe why you are seeking help
*
2. What have you done to deal with the problem?
*
3. What can we do? What are your expectations for coming here?
*
4. As you see yourself, what kind of person are you? Describe yourself
*
5. What, if anything, do you fear?
*
6. Is there any other information we should know?
*
I, undersigned, agree that all information is correct:
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
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