There Is A Solution Inc. Application
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
D.O.B
*
-
Month
-
Day
Year
Date
Identified as:
*
Please Select
Male
Female
Non-Binary
Home of interest
*
New Bedford Men's
New Bedford Men's Grad House
Taunton Men's (K9 Therapy Home)
New Bedford Women's
Falmouth Women's
Roxbury Men's
Dorchester Women's
Fall River Men's
Falmouth Men's
Jamaica Plain Men's
Dorchester Men's Grad House
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
*
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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