Potential Resident Application Form

Potential Resident Application Form

The Well Recovery Home is a non-profit subsidiary of Women at the Well Ministries of PA
Name

First NameLast Name
Maiden Name

First NameLast Name
Name (Alias)

First NameLast Name
Name (Alias)

First NameLast Name
Present Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you live on your own?

YesNo
If no, who do you live with?
Phone Number
Please enter a valid phone number.
Driver's License #
State Issued Photo ID # (if applicable)
Social Security #
Date of Birth
Height
Weight
Hair Color
Eye Color
Birthmarks or distinguishing marks, tatoos, etc.?
Which race or ethnicity best describes you?

American Indian or Native AlaskanAsian or Pacific IslanderBlack or African AmericanHispanicWhite or CaucasianMultiple Ethnicities
Marital Status

SingleMarriedSeparatedDivorcedRemarriedWidowed
How long were or have you been married?
Do you have issues in having healthy relationships?

YesNo
Do you have a child/children? If so, how many?
What is their gender and ages?
Child/Children's Guardian's name, address and phone number:
Emergency Contact Information #1
Family Background Information

If applicable
Mother's Name
Father's Name
Do you have siblings?
Are you an American citizen?

YesNo
Health Information
Do you have medical insurance

YesNo
Company Name and Policy Information
Do you have any health problems? If so, please explain.
Do you wear glasses and/or contacts?

YesNo
Are you pregnant?

YesNo
Have you had any surgeries? If so, please list what surgeries and what year they were performed.
Do you have any medically necessary diet requirements?
Do you have or have you ever had an eating disorder? If so, please list what disorder and the time in your life it occurred.
Do you have any allergies?

YesNo
Please list the medications you are currently taking. Please include the daily dosage, how many doses daily, the amount of medication per dosage, and what the medication is treating.
How would you rate your overall health currently/

ExcellentVery GoodGoodFairPoor
Do you have any disabling condition?

YesNo
If yes, what is the medical diagnosed condition?
When was your last medical exam?

MonthDayYear
Date
Health Provider Information
Have you ever been medically diagnosed with a mental health issue by a health provider?

YesNo
If yes, please explain your diagnosis/condition
Have you ever been diagnosed with any of the following?

DepressionManic DepressionBipolar DisorderSchizophreniaObsessive Compulsion DisorderAnxiety DisorderOther
Have you ever had outpatient treatment for any of the above conditions?

YesNo
Outpatient Healthcare Provider Information
Have you ever had psychiatric in-patient care? If yes, what was the reason for your in-patient stay?
In-patient Healthcare Provider Information
Do you have any other concerns regarding your health that you would like to share?
Drug Use History
Which of the following drugs have you abused, used in excess, or feel you have an issue with?

AlcoholAmphetaminesCocaineHeroinInhalantsLSD/HallucinogensMarijuanaOpiatesSedativesPsychotropicsOver the Counter MedsPrescription DrugsOther
What is your drug of choice?
Please list any drugs that you are currently using and how much a day.
Are you currently drinking alcohol? If yes, how much per day?
Do you use any form of tobacco?

YesNo
Are you willing to give up tobacco to be in our program?

YesNo
Have you ever tried to control your drinking/drugging on your own?

YesNo
Have you ever been to another treatment center for your addiction?

YesNo
If yes, where and when?
Spiritual Background
Do you feel like you need God?

YesNo
Do you know or has anyone explained what salvation in Jesus Christ means?

YesNo
Did you attend church as a child?

YesNo
Do you consider yourself saved?

YesNo
Have you ever been baptised?

YesNo
Are you open to learning about the Bible and how Jesus can work to restore your life?

YesNo
Do you have a religious preference or are you a member of a church or consider yourself as part of a specific church? If yes, please list that.
Legal Status
Are you currently involved in any lawsuits?

YesNo
Are you the plaintiff or defendant?

PlaintiffDefendant
Have you ever been charged with a DUI or DWI? If yes, how many?
Has your driver's license ever been suspended or revoked Y/N? If yes, why and when did that happen?
Have you ever been incarcerated Y/N? If yes, what were the charges and how long was your sentence?
Are there any charges pending against you currently Y/N? If yes, please explain:
Do you have any court dates currently scheduled or pending Y/N? If yes, when?
Are you currently on probation or parole Y/N? If yes, how long and how much time remains?
How often do you need to report?
Probation Officer's Name and Phone #
Have you ever been convicted of a sexual crime Y/N? If yes, what was the circumstances of those charges/
Are you required to register as a sex offender Y/N? If yes, what county and state?
Please list any outstanding debts and fines you currently have.
What is the highest level of education that you completed?
Can you read books on your own and understand them?
Are you receiving any benefits or government aid such as acess, SSD, SSI, unemployment or something else Y/N? If yes, please list:
Why are you seeking a faith-based program?
Why would you like to be accepted by the Well Recovery Home?
What are your 5 main goals you hope to achieve during your stay at the Well?
STATEMENT OF TRUTH

I certify that all the information in this document is accurate and true to the best of my knowledge and has been fully completed by me. I understand that any false or incomplete information may result in disqualification of any application for entrance into the Well Recovery Home or any subsidiary of Women at the Well Ministries of PA.
Signature

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Potential Resident Application Form

Family Background Information

Health Information

Drug Use History

Spiritual Background

Legal Status