HOH of Franklin County RESIDENT APPLICATION

House of Hope of Franklin County Inc.

Phone: 717-414-7666 Fax: 717-496-8780

230 E. Queen Street, Chambersburg, PA 17201

Email: lhateheroin@comcast.net
HOUSE OF HOPE of Franklin County -APPLICATION FOR RESIDENCY
Date of application

MonthDayYear
Date
Name
Date of birth

MonthDayYear
Date
Last permanent address
City
County
State
Zip
Phone number
DRUG USAGE
1. Drug of choice
1. Date of last use

MonthDayYear
Date
2. Drug of choice
2. Date of last use

MonthDayYear
Date
3. Drug of choice
3. Date of last use

MonthDayYear
Date
4. Drug of choice
4. Date of last use

MonthDayYear
Date
CURRENT LEGAL STATUS
If currently incarcerated, expected release date:
Date of last offense

MonthDayYear
Date
Last offense
Release date

MonthDayYear
Date
Pending charges
Do you owe fines?
if so, how much?
Court Date

MonthDayYear
Date
Parole or Probation Officer
County
FINANCIAL STATUS
Employeer
How long?
Other Income?
Do you have health insurance?
Do you have Medicare/Medicaid/Private Insurance?
MEDICAL/PHYSICAL STATUS
Current medical issues
Are you pregnant?
Have you received prenatal care?
Allergies
Health Care Provider
MENTAL HEALTH STATUS
Diagnosis(s)
Mental Health Provider
List any Medical Treatments/Counseling (include where and dates)
Place 1: where and dates
Place 2: where and dates
Place 3: where and dates
MEDICATIONS
Medication 1
What is it for?
Medication 2
What is it for?
Medican 3
What is it for?
Medication 4
What is it for?
Medication 5
What is it for?
PRIOR TREATMENT PROGRAMS
1. Where and dates
2. Where and dates
3. Where and dates
4. Where and dates
5. Where and dates
Do you have a sponsor or mentor?
Who is supportive of your recovery?
Relationship to you?
DEPENDENT CHILDREN
Name of Child 1, their age and who they are currently living with?
Name of Child 2, their age and who they are currently living with?
Name of Child 3, their age and who they are currently living with?
Name of Child 4, their age and who they are currently living with?
Do you owe child support
Amount
Applicant's Signature

Clear
Date

MonthDayYear
Date
House of Hope Phone: 717-414-7666 Fax: 717-496-8780 230 E. Queen Street, Chambersburg, PA 17201 Email: lhateheroin@comcast.net
A journey of a 1000 miles begins with the first step to a better life.
Should be Empty: