There Is A Solution LLC Application
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
D.O.B
*
-
Month
-
Day
Year
Date
Are you in treatment or a halfway house?
*
Please Select
Yes
No
If so where?
*
Home of interest
*
New Bedford Men's
New Bedford Men's Grad House
New Bedford Women's
Dorchester Women's
Fall River Men's
Bourne Women's
Falmouth Men's (Special Permission Only)
Have you been a guest in one of our homes in the past?
*
Yes
No
If yes, which one? Reason for leaving?
Are you associated with any guest in or applying to get in one of our homes
*
Yes
No
If yes to the above question who is the guest in you speak of (with holding this information may result in a discharge or a denial of the application)
*
Do you know anyone currently living in any of our homes?
*
yes
no
Phone Number Applicant
*
Email (please list one that you will be able to correspond with IE, moms, dads, clinicians, recovery coach's, PO's, etc etc)
*
example@example.com
Email of case manager
Phone Number of person filling out application
*
Can you have a biopsychosocial including all new addendums faxed to 844 232 5985 (if in a PHP or IOP biopsych is mandatory)
*
yes
no
Are you currently enrolled in a PHP or IOP?
*
Please Select
Yes
No
If so, where?
Have you ever been diagnosed with any of the following disorders (select yes or no) • Depression • Generalized Anxiety Disorder • Bipolar Disorder• Schizophrenia • Post Traumatic Stress Disorder• Sleep Disorders• Eating Disorder• Body-Dysmorphic Disorder • Suicidal or Ideations• Homicidal • Obsessive Compulsive Disorder• ADHD/ADD • Borderline Personality Disorder
*
Yes
No
Have you ever been experienced any of the following (select yes or no) • Hair-pulling • Skin Picking • Extreme Emotional Mood Swings • Explosive Anger or Rage • Panic Attacks • Mania • Delusions of Grandeur • Social Anxiety • Hallucinations (Auditory or Visual) • Short Term Memory Loss • Long Term Memory Loss •Hoarding
*
Yes
No
Have you ever experienced any addictive behavior in the following areas (select yes or no) • Sex • Gambling • Food • Pornography • Shopping • Co-Dependency • Stealing • Video Game/Social Media
*
Yes
No
Had seizure in the past 5 years?
*
Yes
No
If yes, what was the cause and the outcome?
*
On Probation or Parole
*
Probation
Parole
No
PO First and Last name
First Name
Last Name
PO Phone Number
Do you have any open cases or existing warrants?
*
Yes
No
If Yes....please explain:
History of any violent,sexual or arson related crimes
*
yes
no
History of gang related violence
*
yes
no
Are you employed
*
yes
no
If employed name and number of employee
*
If no employment, what will be your SOURCE of payment
*
Have you applied for any type of scholarship or funding?
*
Yes
No
If yes which ones?
*
Sobriety Date
*
Able to pass a drug test (THC included)
*
yes
no
If not able to pass a drug test why
*
Name and number of sponsor
*
Name and number of 2 character references
*
List of ALL medications
*
Name of Primary Care Physician
First Name
Last Name
Submit
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