Application for Admission

Application for Admission

In order for your application to be reviewed it must be completely filled out
Date:*

MonthDayYear
Date
Applicant Full Name:*

First NameMiddle NameLast Name
Social Security Number:*
DOC Number (if applicable):
Date of birth:*

MonthDayYear
Date
Age:*
Sex you identify with:*
Referring Agency:
Referring Agency Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Referring Person:
Referring Person's Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Referring Person's Fax:
Please enter a valid phone number.Format: (000) 000-0000.
Substance Use History
Have you ever been with TTHI before?*

YesNo
Have you ever been to other treatment facilities?*

YesNo
If yes, where and when?
Primary drug of choice:
Age of first use:
Frequency of use (daily, weekly, monthly, etc.):
Method?
Secondary drug of choice:
Age of first use:
Frequency of use (daily, weekly, monthly, etc.):
Method?
Third drug of choice:
Age of first use:
Frequency of use (daily, weekly, monthly, etc.):
Method?
Medical Insurance
Do you have medical insurance?*

YesNo
If yes, what is the name of your insurance company?
Policy holder name:

First NameLast Name
Policy number:
Insurance company phone number:
Type of coverage:

PPOHMOOther
If other, please explain:
Medical History
Date of last TB test?
If within 12 months of your release date, please attach a copy to this application (bottom of application) or bring with you upon admission
Do you have any present medical conditions?*

YesNo
If yes, please list:
Are you able to get on a top bunk?*

YesNo
Are you able to walk up and down stairs?*

YesNo
Psychiatric History
Do you have a past or present psychiatric diagnosis?*

YesNo
If yes, where and when were you diagnosed?
If yes, what was the diagnosis?
Medications
Are you currently taking medications?*

YesNo
If yes, please list medications (name of drug) and dosage (mg, how are you supposed to take it):
Military History
Are you a Veteran?*

YesNo
If yes, what branch did you serve in?
If yes, dates of service:
What was your discharge type:
Employment History
Place of last employment:
Date of employment:
Type of work experience that you have:
Income Status
Do you receive income?*

YesNo
If yes, what kind:

SSISSDIUnemploymentWagesPensionOther
If other, please explain:
Monthly income amount?
Do you have any financial responsibilities?*

YesNo
If yes, what are they:
Legal History
Any present legal issues?*

YesNo
If yes, please list the charges, dates, and locations:
Have you ever been to prison?*

YesNo
If yes, please list when and where:
If yes, please indicate release date(s):
If yes, please provide your DOC #:
Are you currently on probation, parole, or community service?*

YesNo
If yes, please explain:
If yes, please provide your probation officer's name, address, and phone number:
Education
Highest grade completed:*
Do you have a GED:*

NoYes
If you have a college degree, what is the degree and in what field of study?
Marital Status
What is your current relationship status?*
Do you have chidlren?*

YesNo
If yes, how many and what are their ages?
If yes, whom do your children reside with?
If yes, where do your children reside?
If yes, do you have parental rights?

YesNo
Please explain if your family is supportive of you getting help for your substance use disorder?*
Living Arrangement
Are you homeless?*

YesNo
If yes, how many times have you been homeless in the past 5 years?
If yes, during your periods of homelessness how long have they been?
If not homeless, what is your current address?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Emergency Contact Person
Name:*

First NameLast Name
Relationship:*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Your Goals and Plans
What do you hope to accomplish if you are admitted into The Transition House?*
What are your short term goals?*
Define your long term goals?*
What is your plan to obtain employment? Do you have a resume?*
What are your plans to obtain long term permanent housing?*
File Upload

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Application for Admission

Substance Use History

Medical Insurance

Medical History

Psychiatric History

Medications

Military History

Employment History

Income Status

Legal History

Education

Marital Status

Living Arrangement

Emergency Contact Person

Your Goals and Plans