Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Age
*
Your Sex/Gender
*
Male
Female
Race/Ethnicity
*
White or Caucasian
Native Indian or Alaskan Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Pacific Islander
Social Security Number
*
Address
*
If you do not have residency, please write in NA.
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Email
*
Have you ever been arrested/changed and/or convicted of any crimes? If so, please explain. If not, please write "No."
*
Have you ever been on probation or parole?
*
Yes
No
If yes, was it as a:
Juvenile
Adult
If on probation or parole, what is the name and phone number of the officer?
Do you own any weapons?
*
Yes
No
If so, please list the weapons you own below:
Describe your current family/support system situation below.
*
(Family, friends, neighbors, church, etc.)
How much involvement would your like your family to have in your treatment and program?
*
None
Somewhat Involved
Involved
Very Involved
Do you have children?
*
Yes
No
If so, how many children do you have?
1
2
3
4 or more
Have you been troubled with/bothered in the last 30 days by family problems?
*
Select One
Yes
No
Do you currently belong to a religious group an/or practice beliefs? If so, please share below. If no, write "NA."
*
Are there any cultural considerations Hope Station & Thrive should know about that will impact your treatment?
*
(This may include personal space, communication, dress, food/eating habits, relationships, values, beliefs or work habits.)
List any diagnosis, medications, current services or history of hospitalizations for mental health:
If so, please explain:
If so, please explain:
Have you had any suicidal attempts or thoughts?
*
Yes
No
Have you had any homicidal attempts or thoughts?
*
Yes
No
Are you currently undergoing any Court Ordered Treatment or have been institutionalized?
*
Yes
No
Date Institutionalized
MM
DD
YYYY
Institutionalized Release Date
MM
DD
YYYY
Are you currently taking any medications?
*
Yes
No
If yes, please list them:
Do you have any limitations that could keep you from working?
*
Yes
No
If yes, please explain:
Are you a cigarette or tobacco user?
*
Yes
No
If yes, how many packs a day do you use? How many years have you been using?
Which of the following have you ever used three times a week? And how many year did you use three times a week?
*
Alcohol, Heroin, Downers, Amphetamines/Speed, Cocaine, Weed/Pot, Hallucinogens, Inhalants: Paint, Glue, Other: opiates/Analgesics, Methadone, or other drugs
Have you ever overdosed on drugs?
*
Yes
No
If so, explain and did you get treatment?
What is the longest you have voluntarily maintain your sobriety?
*
0-6 months
6 months - 1 year
1 year - 2 years
2 years +
Have never used
Since sobriety have you experienced withdrawal symptoms?
Have you ever experienced employment problems due to drug and alcohol use?
*
Yes
No
If so, please explain:
Have you ever experienced relationship problems due to drug and alcohol use?
*
Option 1
Option 2
If so, please explain:
Have you been arrested or convicted for an alcohol or drug related charge?
*
Option 1
Option 2
If so, please explain:
