Mercer County House of Hope

Intake Assessment Application
Applicant Name:*
Date:*

MonthDayYear
Date
Current Physical Address:*
Home Phone:*
Cell Phone:*
Age:*
I acknowledge that I can provide a valid Social Security number.
Drivers License?*

YesNo
Marital Status:*

MarriedDivorcedSingleSeparatedWidowedPartnership
Education Level:*

High SchoolGEDCollegeTrade SchoolGrad School
Are you a veteran?*

YesNo
Are you pregnant?*

YesNo
Referred By:*
Do you have communication problems.*
Medical Information
Do you have allergies?*

YesNo
If yes please list them below.
Are you currently on medication?*

YesNo
If yes please list them below.
Have you had any surgeries?*

YesNo
If yes, list and date them below.
Mental Health Information
What has your diagnosis been?*
Who made your diagnosis?*
Are you suicidal?*

YesNo
Are you homicidal?*

YesNo
Have you attempted suicide?*

YesNo
Have you attended any treatment programs in the last year?*

YesNo
If yes please list them below.
Have you completed any?
History
Last date of substance abuse:*

MonthDayYear
Date
When did your addictions start?*
Whats the longest period of time you stayed sober?*
What is your drug of choice?*
Has your addiction caused blackouts or psychosis?*
Do other family members suffer from addictions?*
Who is the person who supports you the most?*
Employment History
Do you have any work history?*
Are you able to work now?*
Legal
Are you directed by the court for services?*

YesNo
Have you ever been arrested, other than for traffic offenses?*

YesNo
If yes, please list them below.
Are you presently on parole or probation?*

YesNo
Name of Officer:*
Personal
Do you attend AA, NA, or any other programs currently?*

YesNo
If yes, list and date them below.
Do you have any children? How many? Ages?*
Do you have a religious background?*
Are you willing to commit to 8 months here at the House of Hope?*

YesNo
Are you willing to have your income monitored?*

YesNo
Personal Opinion
What does your Rock Bottom look like to you?*
Why do you feel this program would be a good fit for you?*
What are your expectations while you are resident here at the House of Hope?*
Signature

Clear
Mercer County House of Hope P.O. Box 636, Celina, OH 45822 MercerHouseofHope.com
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Intake Assessment Application