Contact – Hope Haven Residences

Refer Form

First Name

Middle/Maiden

Last Name

Date of Interview

Date Admitted

Referred By

Address

Street Address

Address Line 2

City

State

Zip Code

Country

Zip Code of Last Permanent Address

Social History

Race

Age

Date of Birth

Mother's Name (Married & Maiden)

Middle/Maiden

Last Name

Father's Name

Middle/Maiden

Last Name

Prior Admission to Hope Haven?

Yes

Last School Grade Completed

Did you like school?

Yes

Why or Why Not?

Are you presently enrolled in school?

Yes

Are you currently on State or Federal probation?

Yes

Do we have your criminal background report?

Yes

Employment History

Types and Skills

Occupation

Last Employer

Is this your current employer?

Yes

VR involvement?

Yes

Did you serve in the military?

Yes

Income Information

Any source or type of income?

Yes

Are you in the process of filing disability?

Yes

Do you receive Medicaid?

Yes

Do you receive Medicare?

Yes

History of Addiction/Alcoholism

Do you have a history of the following (select all that apply)

Blackouts

DTs

Epilepsy

Neuritis

Hallucinations

Date of Last Drink/Use

Age of First Drink/Use

At what age did alcohol/drugs become a problem?

Alcohol/drug related arrests?

Yes

Other arrests?

Yes

Previous Treatments (List where and when)

Sponsor?

Other arrests?

Yes

Psychological History

Have you ever been a patient in a mental hospital?

Yes

Have you ever had a mental health assessment/evaluation?

Yes

Have you had any of the following in the last two months?

Financial Burdens

Lack of Sexual Desire

Irritability

Family Problems

Weight Loss

Staring Spells

Problems with Job

Employment

Separation/Divorce

Has there been abuse in your marriage or intimate relationships?

Yes

How well do/did you get along with your significant other/spouse?

Number

How well do/did you get along with your child(ren)?

Living arrangements prior to treatment?

Number in Household

Do you ever feel afraid of your partner?

Yes

Has there ever been any violence in your intimate relationships? (Example: pushing, pulling, slapping, punching or kicking)

Yes

Has there ever been fighting in your intimate relationships that led to damage or destruction of personal belongings, property, or pets?

Yes

Have there ever been threats to use weapons such as a gun, knives by you or your partner?

Yes

Have you ever had a partner force you to have sex against your will?

Yes

Has physical abuse ever occurred while you were high?

Yes

Has physical abuse ever occurred while your partner was high?

Yes

Have you ever gotten high to cope with the violence in your relationships?

Yes

Have the police ever been called to your home due to fighting?

Yes

Medical History

Family Doctor Last Name

Family Doctor First Name

Address

Street Address

Address Line 2

Address

City

State

Zip Code

Country

Date of last physical examination?

Date of last TB Test:

Result

Positive

Negative

Do you have a history of

Diabetes

Epilepsy

High Blood Pressure

Cancer

Nervous/Mental Disorder

Other

What over the counter medications have you taken in the last 6 months?

What medications are you allergic or sensitive to?

Are you currently on medication(s)?

Yes

Females Only

If you are not female, please skip to the next section.

Are you pregnant now?

yes

# of times pregnant

Last menstrual period date

Flow

Light

Heavy

Abnormal Discharge

Last pap smear date

Results

Breast Exam

Pain

Lump

Discharge

Emergency Contact Information

First Name

Last Name

Phone/Mobile

Relationship

Complete Address

Street Address

Address Line 2

Address

City

State

Zip Code

Consent

Please read and agree to the following

As a resident of Hope Haven, I understand and accept my written responsibilities. In consideration of your admitting me as a resident to Hope Haven, I, for myself, my heirs, assigns or personal representatives, do hereby release you and your staff from any liability for any personal injury or property damage that I may sustain at any time at Hope haven, or on its premises or while I am a passenger in any vehicle, and further agree to hold Hope Haven, Inc. free and harmless from any and all liability in connection therewith:

I agree

Resident Signature

Date