Grace House - Application for Services
Please Complete All Sections of this Form
Name
*
First Name
Last Name
Today's Date
*
-
Month
-
Day
Year
Date
Date of Birth
*
-
Month
-
Day
Year
Date
Place of Birth
*
SSN
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Prior to Admission to Grace House, Were You
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Homeless
Living in Your Own House/Apartment
Staying With Friends or Family
Jail/Rehab
Address (before treatment or incarceration)
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Sex Assigned at Birth
*
Male
Female
Gender Identity (check one)
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Male
Female
Other
Race
*
Ethnicity
*
Marital Status (check one)
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Married
Divorced
Separated
Single
Widowed
Height
*
Weight
*
Do You Have Insurance?
*
Yes
No
Insurance Type
*
Group Number
*
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Last Grade Completed
*
Current Forms of ID (check all that apply)
*
Driver’s License
ID Card
Birth Certificate
Social Security Card
Other
Military Veteran
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Yes
No
Spiritual Beliefs
I Belong to the Following Religion (if applicable)
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Christian
I Believe in a Higher Power, But Do Not Belong to a Religion
Agnostic
Atheist
No Religion
Other
Currently Employed?
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Yes
No
If Yes, Where?
Other Forms of Income
*
Disability/SSI / SSDI
Child Support
None
Other
If Currently in Treatment, Where?
Anticipated Discharge Date, If Applicable
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Month
-
Day
Year
Date
Referring Agency & Telephone
Referring Case Worker/Counselor/Contact Person Name
First Name
Last Name
Telephone
Please enter a valid phone number.
Format: (000) 000-0000.
When Are You Available to Start Treatment at Grace House?
*
Presenting Problems (check all that apply)
Primary Substances
*
Alcohol
Cocaine
Heroin
Fentanyl
Physical Abuse
Sanitation
Inhalants
Marijuana
Tobacco/Nicotine
K2/Spice
MDMA
Hallucinogens
Methamphetamines
None
Other
Mental Health
*
Exposure to Violence
Domestic Violence
Grief
Cyber Crimes
Self Harm
Suicidal Ideation/Attempts
Victim of Discrimination (i.e. Sexual orientation, race, gender)
Eating Disorder
Mental Health Disorder
None
Other
Medical
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Pregnant
Physical Disability
Allergies
Financial needs
None
Other
Physical Environment
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Homeless / Shelter needs
Food needs
Employment needs
Safety needs
None
Other
Legal Problems
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Alcohol Crimes
Drug Charges
Sex Crimes
Crimes against Justice
Public Safety Violations
Fraud/Financial Crimes
Property Crimes
Attempt, Conspiracy/Aiding
Homicide
None
Other
Any Other Information (explain)
LEGAL HISTORY
Do You Have Any Active Warrants Currently? All Warrants Must Be Resolved Before an Interview Can Be Completed.
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Yes
No
Are You Currently Incarcerated?
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Yes
No
If Yes, Explain Current Charges
Facility Type
Jail
Prison
Detention Center
Other
Facility Name
Inmate ID
Scheduled Release Date
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Month
-
Day
Year
Date
Type of Charges
Misdemeanor
Felony
Both
Do You Have Any Charges Pending (county & state)
*
Yes
No
Legal Representation
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Yes
No
If Yes, Name & Telephone
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Are You Currently on Probation?
*
Yes
No
For Probation, What County Are You Required To Report To?
Are You A Repeat Offender?
*
Yes
No
Probation Officer Name
First Name
Last Name
Probation Officer Telephone
Please enter a valid phone number.
Format: (000) 000-0000.
Prior Incarceration/Reason/and Estimated Dates
History of Non-Incarceration Convictions/Reason/Date
MEDICAL HISTORY
Name of Current Physician
First Name
Last Name
Physician Telephone
Please enter a valid phone number.
Format: (000) 000-0000.
Physician Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
HIV
*
Yes
No
Hepatitis C
*
Yes
No
IV Drug Use
*
Yes
No
Drug Allergies
*
Yes
No
Food Allergies
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Yes
No
Are You Currently on Any Type of Medically Assisted Treatment (MAT)?
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Yes
No
If Yes, Please List: (suboxone, sublocade, vivitrol, methadone)
Have You Tried MAT Previously?
*
Yes
No
Was It Successful?
Yes
No
If No, Why?
Identify And Describe Other Medical Problems Or Physical Limitations
Are You Able To Take Medications By Yourself?
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Yes
No
Are You Able To Climb Stairs Without Assistance?
*
Yes
No
History of Seizures:
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Yes
No
Current Medications
*
MEDICAL HISTORY CONTINUED
Substances Used
Age of 1st Use
Frequency
Method: Orally, Injection, Inhaled, Smoked
Date of Last Use
MENTAL HEALTH HISTORY
Do You Have A Mental Health Diagnosis
*
Yes
No
If Yes, Please List DSM 5 With Description and Dates of Diagnosis
Are You Taking Medication For This Condition?
Yes
No
What?
Are You Currently Receiving Psychiatric Services For This Condition?
Yes
No
Where?
Have You Been Hospitalized For Mental Health?
*
Yes
No
If Yes, Please List Dates and Nature
Do You Have a History Of Suicidal Ideation or Attempts?
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Yes
No
If Yes, How Many Times?
Date of Last Attempt
-
Month
-
Day
Year
Date
Do You Have a History of Homicidal Ideation or Attempts?
Yes
No
Have you had any attempts at sobriety without treatment?
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Yes
No
If yes, how many?
Have you been in treatment within the last calendar year?
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Yes
No
If yes, how many times for each?
Detox Only
Inpatient
Outpatient
Please list in order of most recent
#1 - Where / When / Counselor/Probation Officer/Case Worker Name / Contact Info
#2 - Where / When / Counselor/Probation Officer/Case Worker Name / Contact Info
#3 - Where / When / Counselor/Probation Officer/Case Worker Name / Contact Info
Have you had a period of sobriety in the past year?:
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Yes
No
How long did you remain sober?
What did you do to maintain your sobriety and why did you relapse?
What is your motivation for treatment at this time?
How did you hear about Grace House?
*
Client Signature
*
Today's Date
*
-
Month
-
Day
Year
Date
Submit
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