Hickory Hill Recovery Center Application

HONEST ANSWERS ARE REQUIRED FOR ADMITTANCE TO HICKORY HILL RECOVERY CENTER.

DOCCourt OrderedSelf

If you're filling this form out on behalf of the client, leave their information in the in the form below.

Client Name*

First NameLast Name

Social Security Number*

Telephone Number

Date of Birth*

Staff Name*

First NameLast Name

Date*

Time*

Valid State ID Card or Driver's License*

YesNo

Social Security Card*

YesNo

Birth Certificate*

YesNo

Are you willing to sign-up for Food Stamps?*

YesNo

Ever been convicted of a violent crime?*

YesNo

Ever been convicted of a sexual offense?*

YesNo

Upon Acceptance to the program, would you be able to provide a $25 fee for a criminal history background check?*

YesNo

1. Have you ever been a client at Hickory Hill Recovery Center?*

YesNo

If yes, when?

2. Have you ever been in a substance abuse treatment or recovery program before?*

YesNo

If yes, list all:

3. What is your drug of abuse?

a. When was the last time you drank alcohol and/or used drugs?

b. How much did you use or drink?

c. Intravenous drug use?*

YesNo

If yes: what drugs were used?

4. Where have you lived for the past 6 months?

According to the Steward B. McKinney Act, 42 U.S.S. 11301 (1994), a person is considered homeless who "lacks fixed, regular, and adequate night time residence and has a primary night time residency that is (A) a supervised publicly or privately operated shelter designed to provide temporary living accommodations... (B) an institution that provides a temporary residence for individuals intended to be insititutionalized, or (C) a public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human being. "42 U.S.C. 11302 (a) The term "homeless individual does not include any individual imprisioned or otherwise detained pursuant to an Act of Congress or state law." 42 U.S.C 11305 (c)

5. Do you have any pending legal charges or other issues?*

YesNo

Do you have any upcoming court dates?*

YesNo

If yes, please describe, including upcoming court dates:

6. Are you currently in Jail or Prison?*

YesNo

If yes, where?

7. Are you Court Ordered to this program?*

YesNo

If yes, client needs to provide court order prior to arrival to program. Provide County of Court Order and Ordering Judge's Name.

MUST HAVE NO COURT DATES WITHIN 30 DAYS OF ENTERING THE PROGRAM
If court ordered, individual must provide court ordered documentation.

8. Are you currently seeing a Probation / Parole Officer?*

YesNo

If yes, please provide Officer's name and phone number.

9. Have you ever been convicted of a misdemeanor?*

YesNo

If yes, please list all:

10. Have you ever been convicted of a felony in the last 3 years?*

YesNo

If yes, please list all:

11. Are you able to walk unassisted? (Up to 1 mile at a time)*

YesNo

If no, please describe assisted devices required:

12. Do you have Medical Insurance?*

YesNo

13. Are you currently employed?*

YesNo

14. Do you have Medical Insurance?*

15. What is your highest level of education?*

If applicant has no GED, would he like to attend classes to obtain one while in the program?*

YesNo

Please review this section with the client upon application and again immediately after entry to the program. Income means: Any funds that you receive on a regular basis, such as income from assets, workman's comp, SSI/SS/VA pension or disability income, family income, and informal support income. If you are married and not estranged, or separated, from your spouse, the household income will be counted when qualifying you for this program and later on for the housing program. You may not qualify for this program and will have to leave or you may have to pay a portion of your rent when you reach the Phase 1 part of the program (or earlier if moved into a room prior to Phase 1) If anyone in your household has income, you do need to report it upon application to this center. Informal support is when someone gives you money on a regular basis, or when they pay for something on your behalf on a regular basis. If you own a car and they are paying your car payment, or insurance/gas for you, when they bring you items, such as cigarettes, or give you money for them on a regular basis, that is income. If you are spending money to get your hair or nails done, going to the tanning bed, spending money here and there, where did it come from and are you receiving it on a regular basis?

16. What is your current income?*

17. What is your source of income?*

18. Are you receiving financial assistance? (SSI/DISABILITY/TANF/SSDI/VA)*

YesNo

a. If Yes to 16-18, would you be willing to pay rent up to 30% of your income?*

Answering No may make you ineligible for full participation in the recovery program.

Do you have any children?*

YesNo

If yes, what plans do you have for their care?

20. Referral Source:

21. Do you own / lease an Apartment/Trailer/House?*

YesNo

Do you have any medical problems?*

YesNo

Have you ever had a T.B. Skin Test?*

YesNo

If yes, date of last test?

Results of last test?

PositiveNegative

Do you have a T.B. Card?

YesNo

If Positive, were you referred for treatment?

YesNo

Have you ever taken preventative T.B. medications?

YesNo

If yes, when and where?

Are you currently being treated for Psychiatric Problems?*

YesNo

If yes, explain:

Have you ever been admitted to a psychiatric hospital for treatment?*

YesNo

If yes, Name of Facility:

If yes, Reason for admission:

If yes, did you stay longer than three (3) days?:

Dates of stay:

Do you currently feel like hurting yourself?*

YesNo

If the individual answers YES, inform them that they ened to go to a safe place and that we are required to report feelings of self-harm and request that they call the KRCC Crisis Line at 1-800-262-7491

Have you ever attempted suicide in the past?*

YesNo

If yes, how many times?

If multiple times, provide date of most recent occurrence:

Specify treatment plan:

Were you under the influence at the time?

YesNo

Are you currently prescribed or taking any medications?

YesNo

If yes, describe:

How long have you been taking these medications?

Emergency Contact:*

First NameLast Name

Relation:

FriendParentSiblingOther

Address:

City:

State:

Zip:

Phone Number:

Secondary Phone Number

(PLEASE ADVISE THAT CLIENT OR REPRESENTATIVE MUST CALL EVERY MONDAY TO REMAIN ON THE WAITING LIST. FAILURE TO DO SO WILL REMOVE CLIENT FROM THE LIST!)

According to the Steward B. McKinney Act, 42 U.S.S. 11301 (1994), a person is considered homeless who "lacks fixed, regular, and adequate night time residence and has a primary night time residency that is (A) a supervised publicly or privately operated shelter designed to provide temporary living accommodations... (B) an institution that provides a temporary residence for individuals intended to be institutionalized, or (C) a public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human being. "42 U.S.C. 11302 (a) The term "homeless individual does not include any individual imprisoned or otherwise detained pursuant to an Act of Congress or state law." 42 U.S.C 11305 (c)

Hickory Hill Recovery Center

1. Contact Information

2. Medical Information