Resident Application

APPLICATION FOR RESIDENCE AT THE WOMEN'S CARE CENTER

To be accepted into the Women's Care Center an applicant must complete this application. Carefully read and honestly answer all the questions. Living at the Women's Care Center is a privilege, and if you understand its value, it will help you in the maintenance of your sobriety without relapse.

Women's Care Canter does not accept sex offenders or anyone convicted of a violent offense. We currently do not take anyone with an electric monitor. The Center is not a medical treatment facility. The facility does not accept anyone who has been prescribed mood-altering medications.

Date

Social Security No

First

middle

last

Date of Birth

Date

Email Address

example@example.com

Present Address

Street address city state and zip code

Street address, city, state, and zip code.

Is this your residence? Y/N if No, who is the owner/tenant? How are you connected to the owner/tenant?

How are you connected to the ownertenant

Is this a treatment facility

Phone Number

Are you an alcoholic

Date of Last drink

Date

Are you addicted to drugs

Date of Last use

Date

List of all drugs you have used

Do you want to stop using drugs and drinking

Are you willing to participate in the Spiritual program that we offer at Womens Care Center including but not limited to daily devotions Bible studies church attendance and 12step meetings

Are you currently in treatment or incarcerated

If yes where and how long

If yes explain

Do you have any current pending charges

List all criminal convictions including the City County and State for each conviction

Are you a Registered sex offender?

What is your current monthly income

What is your marital status

Do you have children

If yes how many

Do you owe child support

Have you ever been to a treatment facility for drug or alcohol addiction

If yes how many times

When was the last time

Where

Do you have a medical doctor List the names of all doctors you have seen in the last three years

List the names of all doctors you have seen in the last three years.

List all the pharmacies you have used in the last year:

Check those questions to which you answer yes (leave the others blank Has a doctor ever said your blood pressure was too high? Do you ever have pain in your chest or heart? Are you often bothered by a thumping of the heart? Does your heart often race? Do you ever notice extra heartbeats or skipped beats? Are your ankles often badly swollen? Do cold hands or feet trouble you even in hot weather? Has a doctor ever said that you have or have had heart trouble, an abnormal electrocardiogram (ECG or EKG), heart attack, or coronary? Do you suffer from frequent cramps in your legs? Do you often have difficulty breathing? Do you get out of breath long before anyone else? Do you sometimes get out of breath when sitting still or sleeping? Has a doctor ever told you your cholesterol level was high? Has a doctor ever told you that you have an abdominal aortic aneurysm?

Has a doctor ever told you that you have critical aortic stenosis? Are you pregnant?

Comments

Do you now, have, or have you recently experienced: Chronic, recurrent or morning cough? Episodes of coughing up blood? Increased anxiety or depression? Problems with recurrent fatigue, trouble sleeping or increased irritability? Migraine or recurrent headaches? Swollen or painful knees or ankles? Swollen, stiff or painful joints? Pain in your legs after walking short distances? Foot problems? Back problems? Stomach or intestinal problems, such as recurrent heartburn, ulcers, constipation or diarrhea? Significant vision or hearing problems? Recent change to a wart or mole? Glaucoma or increased pressure in the eyes? Exposure to loud noises for long periods? An infection such as pneumonia accompanied by a fever? Significant unexplained weight loss? A fever, which can cause dehydration and rapid heartbeat? A deep vein thrombosis (blood clot)? A hernia that is causing symptoms?

Foot or ankle sores that will not heal?

Persistent pain or problems walking after you have fallen? Eye conditions such as bleeding in the retina or detached retina? Cataracts or lens transplant? Laser treatment or other eye surgery?

Comments

List any prescription medications you are now taking

List any selfprescribed medications dietary supplements or vitamins you are now taking

Date of last complete physical examination

Date

Date of last pap smear and mammogram

Date

Date of your last tetanus shot

Date

Date of last electrocardiogram EKG or ECG

Date

Date of last dental checkup

Date

List any other medical or diagnostic test you have had in the past two years

List hospitalization including dates of and reasons for hospitalization

Date

List of any drug allergies

Check those questions to which your answer is yes (leave others blank Heart attack if so, how many years ago?

Arthritis of legs or arms Diabetes or abnormal blood-sugar tests Phlebitis (inflammation of the veins) Dizziness or fainting spells Epilepsy or seizures

Scarlet Fever Infectious mononucleosis

Abnormal chest X-ray Other lung disease Injuries to back, arms, legs, or joints

Jaundice or gall bladder problems

Do you have any mental illness or diagnoses

Have you ever attempted suicide

If yes please explain mental health or suicide attempts

Do you take prescription or psychotropic drugs

If yes list all medications you take and the reason you take them

Date you would like to enter Womens Care Center

Date

Do you have a valid drivers license

Birth Certificate

Do you have a Social Security Card

Photo Id

List 3 Emergency Contacts: NAME

3

2

List of any special medical requirements you have or need

Do you have any known allergies

If yes then list

With my signature, I hereby declare that Main Street Ministries and Women's Care Center is not responsible for any injury, medical condition, or self-inflicted injury during my stay. It is also my understanding that drug test and breath analysis will be conducted on a random basis, during house meetings and after returning from day and overnight passes or if the Women's Care Center Manager or staff deems it necessary due to erratic, suspicious or unusual behavior. By signing this document, I am giving my consent to be tested by Women's Care Center staff, by way of urinalysis and breath analysis, for the use of drugs and alcohol. I also understand that if any drug test administered to me turns out positive, I will be referred to the Executive Director, and will be immediately expelled from the Women's Care Center. Secondary knowledge: I also understand that if I find out that one of my house mates is using drugs (other than those prescribed for her) or alcohol, and I don't say anything, and it is proven that I was aware of it, I too will be referred to the Executive Director, and could be expelled from Women's' Care Center. I hereby declare that the information provided by me about my medical history and condition is accurate. I understand any untruthful statement or information is grounds for immediate dismissal from the program.

Residents Signature

Date

Womens Care Center Manager

Date

I have read all the material on this form. I have answered each question honestly and want to achieve a

comfortable recovery from alcoholism and/or drug addiction without relapse.

Please list why we should consider your Women's Care Center application.

Why do you think you are ready to change? List three to give goals you want to achieve in the next 6

Please list why we should consider your Womens Care Center application Why do you think you are ready to change List three to give goals you want to achieve in the next 6 months

This document fulfills all state and federal regulations to the Texas Civil Rights Practice and Remedies Code (Section 74.052); the Standards for Privacy of Individually Identifiable Health Information (45 C.F.R. Part 160 and 164); and the federal and state laws pertain to and commonly referred to as "HIPPA," and any and all other acts cited below.

AUTHORIZATION FOR DISCLOSURE RELEASE INFORMATION/MEDICAL RECORDS

Health Insurance Portability and Accountability Act of 1996 45 CFR Subtitle A, Subchapter C, Part 164.512 € (1) (iii)

NAME

SOCIAL SECURITY NO

DATE OF BIRTH

Date

Date of service/treatment to be received/released:

CLASS OF PERSONS AUTHORIZED TO MAKE THE DISCLOSURE:

All physicians and other health care providers who have examined, treated, consulted with, or x-rayed

(applicant's full legal name) and all hospitals, nursing facilities, rehabilitation

facilities, clinic, or laboratories in which I have been and/or currently a patient and/or resident.

You are hereby authorized and directed by the undersigned to give to the bearer of this authorization, or any photo static copy thereof, any and all information relative to the undersigned and named applicant's physical, emotional, and mental condition and permit the bearer to examine x-rays, laboratory reports, and medical records of any kind of which reflects diagnosis, treatment, prognosis, and any other information concerning illness, injuries, or disability. Such information shall specifically include, but is not limited to, itemized billing records/statements, history & physical, operative reports, lab/pathology reports, consultation reports, physicians' orders, discharge/death summary, x-ray reports/images, other radiographic reports/images, emergency room records, face sheets, nurses' notes, flow sheets, pharmacy and medication records, care plans, assessment tools, screening tools, summaries, social workers, legal, and monitor strips, readouts or printouts. I understand that the specified information to be received/released may include, but is not limited to: history, diagnosis and/or treatment of drug or alcohol abuse, mental illness, psychological and/or psychiatric treatment, counseling records/note, genetic testing or communicable disease, including Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS You are hereby authorized and directed to make available all such information for inspection and copying.

DURATION OF THIS AUTHORIZATION:

This authorization expires one (1) year from the date signed.

I understand that I may revoke this authorization in writing at any time by contacting the Women's Care Center, except to the extent that action has been taken in reliance upon the authorization. I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure and no longer protected.

I understand that I have a right to a copy of this authorization.

I understand that treatment or payment cannot be conditioned on my signing this authorization, except in certain circumstances, such as for participation in research programs, or authorization of the release of testing results for pre- employment purposes.

A photostatic copy of this authorization shall be considered as valid as the original. This authorization applies to Women's Care Center, as the releaser/receiving institution and recipient of all records and information contained in this notice.

HIV

WOMEN'S CARE CENTER

AUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH INFORMATION

DESCRIPTION OF INFORMATION TO BE DISCLOSED:

RIGHT TO REVOKE: