Grace House - Application for Services

Grace House - Application for Services

Please Complete All Sections of this Form
Name

First NameLast Name
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Place of Birth
SSN
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Prior to Admission to Grace House, Were You
Address (before treatment or incarceration)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Sex Assigned at Birth
Gender Identity (check one)

Other
Race
Ethnicity
Marital Status (check one)
Height
Weight
Do You Have Insurance?
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)

Other
Military Veteran
Spiritual Beliefs
I Belong to the Following Religion (if applicable)
Currently Employed?
If Yes, Where?
Other Forms of Income
If Currently in Treatment, Where?
Anticipated Discharge Date, If Applicable

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Referring Agency & Telephone
Referring Case Worker/Counselor/Contact Person Name

First NameLast 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

Other
Mental Health

Other
Medical

Other
Physical Environment

Other
Legal Problems

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.
Are You Currently Incarcerated?
If Yes, Explain Current Charges
Facility Type

Other
Facility Name
Inmate ID
Scheduled Release Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Type of Charges
Do You Have Any Charges Pending (county & state)
Legal Representation
If Yes, Name & Telephone
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Are You Currently on Probation?
For Probation, What County Are You Required To Report To?
Are You A Repeat Offender?
Probation Officer Name

First NameLast 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 NameLast Name
Physician Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
HIV
Hepatitis C
IV Drug Use
Drug Allergies
Food Allergies
Are You Currently on Any Type of Medically Assisted Treatment (MAT)?
If Yes, Please List: (suboxone, sublocade, vivitrol, methadone)
Have You Tried MAT Previously?
Was It Successful?
If No, Why?
Identify And Describe Other Medical Problems Or Physical Limitations
Are You Able To Take Medications By Yourself?
Are You Able To Climb Stairs Without Assistance?
History of Seizures:
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
If Yes, Please List DSM 5 With Description and Dates of Diagnosis
Are You Taking Medication For This Condition?
What?
Are You Currently Receiving Psychiatric Services For This Condition?
Where?
Have You Been Hospitalized For Mental Health?
If Yes, Please List Dates and Nature
Do You Have a History Of Suicidal Ideation or Attempts?
If Yes, How Many Times?
Date of Last Attempt

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Do You Have a History of Homicidal Ideation or Attempts?
Have you had any attempts at sobriety without treatment?
If yes, how many?
Have you been in treatment within the last calendar year?
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?:
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

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Grace House - Application for Services

Spiritual Beliefs

Presenting Problems (check all that apply)

LEGAL HISTORY

If Yes, Name & Telephone

MEDICAL HISTORY

MEDICAL HISTORY CONTINUED

MENTAL HEALTH HISTORY

If yes, how many times for each?

Please list in order of most recent