Application for Admission
In order for your application to be reviewed it must be completely filled out
Date:
*
-
Month
-
Day
Year
Date
Applicant Full Name:
*
First Name
Middle Name
Last Name
Social Security Number:
*
DOC Number (if applicable):
Date of birth:
*
-
Month
-
Day
Year
Date
Age:
*
Sex you identify with:
*
Please Select
Male
Female
Transgender
Referring Agency:
Referring Agency Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referring Person:
Referring Person's Phone:
Please enter a valid phone number.
Referring Person's Fax:
Please enter a valid phone number.
Substance Use History
Have you ever been with TTHI before?
*
Yes
No
Have you ever been to other treatment facilities?
*
Yes
No
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?
*
Yes
No
If yes, what is the name of your insurance company?
Policy holder name:
First Name
Last Name
Policy number:
Insurance company phone number:
Type of coverage:
PPO
HMO
Other
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?
*
Yes
No
If yes, please list:
Are you able to get on a top bunk?
*
Yes
No
Are you able to walk up and down stairs?
*
Yes
No
Psychiatric History
Do you have a past or present psychiatric diagnosis?
*
Yes
No
If yes, where and when were you diagnosed?
If yes, what was the diagnosis?
Medications
Are you currently taking medications?
*
Yes
No
If yes, please list medications (name of drug) and dosage (mg, how are you supposed to take it):
Military History
Are you a Veteran?
*
Yes
No
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?
*
Yes
No
If yes, what kind:
SSI
SSDI
Unemployment
Wages
Pension
Other
If other, please explain:
Monthly income amount?
Do you have any financial responsibilities?
*
Yes
No
If yes, what are they:
Legal History
Any present legal issues?
*
Yes
No
If yes, please list the charges, dates, and locations:
Have you ever been to prison?
*
Yes
No
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?
*
Yes
No
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:
*
No
Yes
If you have a college degree, what is the degree and in what field of study?
Marital Status
What is your current relationship status?
*
Please Select
Single
Married
Long-term unmarried relationship
Divorced
Seperated
Widowed
Do you have chidlren?
*
Yes
No
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?
Yes
No
Please explain if your family is supportive of you getting help for your substance use disorder?
*
Living Arrangement
Are you homeless?
*
Yes
No
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
City
State / Province
Postal / Zip Code
Phone Number:
Please enter a valid phone number.
Cell Phone Number:
Please enter a valid phone number.
Emergency Contact Person
Name:
*
First Name
Last Name
Relationship:
*
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
Please enter a valid phone number.
Cell Phone Number:
Please enter a valid phone number.
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
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: