Name
*
First Name
Last Name
Date of birth
*
Age
*
Social Security Number
*
Phone
*
(###)
###
####
Mailing Address
*
Driver's License
*
Yes
No
Valid Photo ID
*
Yes
No
Birth Certificate
*
Yes
No
Social Security Card
*
Yes
No
Marital Status
*
Yes
No
Do you Have Children?
*
If Yes, What is Their First Name and Age?
Who is caring for your children
Are you currently pregnant?
*
Are you currently in a relationship?
*
If yes, name
Are they currently using drugs or alcohol?
If no, when was your last relationship
*
Name
Did they use drugs or alcohol?
Are you in contact with your family?
*
Do they support you?
*
If yes, in what ways do they support you (emotionally, financially, physically, spiritually, etc.)?
What is your drug of choice?
*
Current or past IV drug user?
*
When did you last use drugs or alcohol?
*
What did you use?
*
Have you been in treatment before?
*
How many times?
Reason for leaving treatment
Facility(s) and dates of previous treatment
What is your longest period of sobriety/clean time?
*
What contributed to your relapse?
Why is this time different for wanting treatment?
Do you currently have charges against you?
*
If yes, have you been sentenced or are you applying for reconsideration? EXPLAIN
Past Charges
Do you currently have a CPS case? If yes, what county is your case in:
*
EXPLAIN:
Please provide your case worker's name and phone number
If you have a Provider, please provide the same information
Have you ever been convicted of a sex or violent crime? EXPLAIN
*
Do you have an attorney?
*
If yes, what is their contact information
Are you court ordered to a program?
*
Are you currently on Probation, in Drug Court, Day Report, or on Home Confinement?
*
If yes, please provide name and contact information
Do you have any type of GPS device?
*
Have you ever been diagnosed with any type of Mental Health Condition?
*
If yes, please provide the following information
What is your diagnosis?
Doctor or facility that diagnosed you
Contact Information
Do you currently have any medical conditions that require medications, doctor's appointments, testing, etc.?
*
Please list condition(s)
Do you agree for Serenity Pointe to have access to your medical history?
*
Current medications or medications that are needed (name, mg/dosage, prescribed for?)
*
Do you receive Medicaid or any other type of medical insurance?
*
Have you applied for Medicaid?
*
Isolating from others
*
yes
no
Self-mutilation
*
yes
no
Attempted suicide
*
yes
no
Burned or cut yourself
*
yes
no
Gambling
*
yes
no
Sex addiction
*
yes
no
Thrill seeking
*
yes
no
Over or under eating
*
yes
no
Other
Do you have ANY income?
*
Are you eligible for food stamps?
*
Name:
*
Contact Information:
*
Do you have a high school diploma or GED?
*
Are you willing to participate in volunteer activities?
*
How did you hear about Serenity Pointe?
*
Have you ever been on our waiting list before but never became a resident? EXPLAIN
*
Why do you want to be a resident at Serenity Pointe? Why is it necessary? What do you hope to get from our program?
*
Can you shower without assistance?
*
Can you prepare your own meals?
*
Can you dress yourself without assistance?
*
Can you provide/ conduct your own hygiene?
*
Can you walk more than 3 flights of stairs?
*
Date
MM
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