Inpatient Application Assessment
Client Information
Client Name
Mr.
Mrs.
Miss.
Prefix
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Age
Email Address
example@example.com
Contact Number
Please enter a valid phone number.
Address
What issues have you seeking recovery?
Please describe in detail any addiction isssues, abuse, criminal or dfcs cases.
Please describe your situation.
Legal issues will not disqualify you from the Abba House program.
How long have you been facing this problem?
Less than a month
1-6 months
1-5 years
More than 5 years
How intense is this problem?
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
How do your life-controling issues effect your daily life?
Life-controlling issues: Drug addictions, self-harm, depression, eating disorders, toxic relationships, etc.
What do you expect from your recovery program?
Ex: to maintain sobriety, to get custody of my children back, to satify the courts, to build healthy support systems, etc.
Do you have a valid drivers license?
Yes
No
Suspended due to DUI/Child Support
N/A
Please select the symptoms that you experienced in the last 60 days?
Sadness
No motivation
Not hungry
No need for sleep
Hopeless/Helpless
Lack of interest
Sleep too much
Hearing/Seeing things
Fearful
Implusive
Can't sleep
Panic attacks
Feeling worthless
Guilt
Rage/Violence
Victim of Abuse
Abuse of others
Obsession for drugs
Other
Have you ever contemplated suicide?
Yes
No
N/A
Have you ever had a trauma?
Yes
No
N/A
Are you pregnant now?
Yes
No
N/A
Do you have children?
Yes
No
Rights were terminated
Number of children & what are age are they?
Are you at risk for HIV/AIDS?
Yes
No
N/A
Do you smoke any forms of tobacco?
Yes
No
N/A
Please describe any past trauma you've expierenced.
Are you having any problems with alcohol?
Yes
No
N/A
What medical issues do you currently have or have had in the past?
Are you having any problems with pills or illegal drugs?
Yes
No
N/A
Please give details.
Who is in your family?
How are the relationships in your family?
Good
Fair
Poor
Close
Stressful
Distant
Other
Are there any of the following problems in your family?
Conflict
Abuse
Stress
Loss
Divorce
Leave
Other
What is your marital status now?
Single
Married
Living as Married
Divorced
Widowed
Never Married
What is your highest level of education?
No education
High school diploma
Graduate school
College degree
Masters degree
Other
Do you have any open/pending legal charges?
Yes
No
N/A
Please provide us with your criminal arrest history (including non-convictions and juvenile charges)
What is your current employment status?
Full time employed
Part time employed
Seasonal worker
Unemployed looking for a job
Unemployed not looking for a job
Other
Do you have an open DFCS case?
Yes
No
Not sure
How do you plan on covering the tuition costs of your program?
If you want to apply for a scholarship or partial scholarship please include that information here.
Please list any allergies or medications.
Anything you would like us to know about you.
Please list your previous employment history/skills/experience
Jobs you have had in the past, how have you supported yourself?
Submit
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