Heart of Hannah Intake Application

 

Date of Intake: ____________________________________________________

Name: ___________________________________________________________

Address: __________________________________________________________

City: ____________________________State:___________Zip________________

Weight:______________Height: ____________________

Home Phone: ___________________________Cell: _________________________

Nationality: _________________

Date of Birth: _______________

Social Security Number _________-________-____________

Who to notify in case of emergency: _______________________________

Your relationship to this person: __________________________________

Phone number to this person: ____________________________________

Married _____Divorced ____Single _____Separated_____

Do you have a Boyfriend ______ His name: _________________________

Spouse Name: ______________________

Marriage License is required if necessary! Common law marriage is not acceptable!

S.C. Driver’s License  ________________________

S.C. ID # __________________________________

If you have lost your license what charges do you have and what would it take to get them back? _____________________________________________________

Are you Court Ordered? __________Are you on Parole? ____Probation?_______

Agent’s Name: ____________________City/State__________________________

What is your addiction? ______________________________________________________________________________________________________________________________________

How long have you been using? ________________________________________

What is the longest that you have ever been clean? _________When?_________

Have you ever served time in jail? _____________When?___________________

How long did you serve? _____________________Where? _________________

What charges? ____________________________________________________

Do you have any outstanding charges? ___________

What? ___________________________________________________________

Are you a listed sex offender? _____yes ______no

Education Level ___________________Did you graduate? _______________

College_____How many years______What did you major in? _____________

What are your qualifications for employment? ______________________________________________________________________________________________________________________________________

Do you receive food stamps? ______How much? __________________________

Medicaid: _____Medicare _________

Do you have any financial obligations? ____________

What & How Much? _____________________________________________

Do you pay child’s support? _______How much? ______________________

Who will pay this for you until you can pay? __________________________

Have you ever been admitted to a state hospital or a mental facility? ______________________Where? __________________________________

Are you currently working with mental health? ______________

Explain why: ___________________________________________________________________

Counselors Name: ______________________What office: ___________________

Phone Number _________________________

Have you had any Mental Illness in your family? ______________

List any health problems and medication that you take: _________________________________________________________________________________________________________________________________________________________________________________________________________

Have you ever been hospitalized for mental health treatment or evaluation? _____________If yes, where__________________________________________

Have you had in/out patient treatment? _____________When?______________

Where? ____________________________

Do you ever hear voices or sounds? __________

Have you ever been to a Detox? ____________Where? ____________________

Have you ever overdosed? __________Date: _________________________

Have you ever had a HIV test and TB test done?___What were the results? _____

 

Do you smoke cigarettes? _____YOU CAN ONLY GO OUT ONE AT A TIME!!!

Do you think that you are a healthy person? ________________

Have you ever gotten professional counseling? ___________

Name of Counselor._________________Phone # ____________________

Are you on Parole/Probation? ________For how long? ____

For what reason? ____________________________________________

Are there any warrants out for you in S.C. or any other state? ________________________________________________________

Do you pay court cost? _____ How much? ___________

Do you pay restitution? _____How much? ___________

Are there any legal matters that you are currently working on or are supposed to be working on? ___________What? _____________________________________

Do you have children? __________What are their ages? _____________________

Where so they live? ___________With Whom? ____________________________

If Social Service is involved with your children, state the case workers name and phone number. ______________________________________________________________________________________________________________________________________

Religious Preference? _________________________________________________

How would you describe your relationship with the Lord? ______________________________________________________________________________________________________________________________________

Have you ever ask Jesus Christ to be Lord over your life? _____When? _________

What would you consider to be your greatest struggle? __________________________________________________________________

Do you ever pray and read the Bible? ____________How Often? _____________

Do you struggle to stay consistent in daily personal devotions? ___________________________________________________________________

Do you Journal? _____________________________________________________

Why do you feel that you need our Renewal/Recovery program?

_________________________________________________________________________________________________________________________________________________________________________________________________________

Is everything true on this application? ______Everything is kept confidentially. Any false statements could keep you from staying in our program.

Are you willing and can pay $125.00 a week for service fees? (The six weeks has to be paid up front and is non-refundable)? After 6 weeks you would work in the daytime and go to our evening classes and should be able to pay your service fees by working. Additional $50.00 registration and book fee upon arrival.

Who is paying the six weeks? _____________________________ You must let them know that the monies are non-refundable if they did not come with you at your Intake.

By signing below, I have been honest and open on my answers.

_________________________________________________

Signature

_________________________________________________

Date

 

Name:________________________________________________

Date: _____________________

 

Medication:

            Name of Med.                     Dosage                      Mg.                 How many

1. _______________________________________________________

2. _______________________________________________________

3. _______________________________________________________

4. _______________________________________________________

5. _______________________________________________________

6. _______________________________________________________

7. _______________________________________________________

8. _______________________________________________________

9. _______________________________________________________

10. _______________________________________________________

 

What is the name of your Doctor: ___________________________

Phone number for Doctor: _________________________________

Dispose of Medication:

 

I, ______________________________________________________have ask H.O.H. to dispose of my

 

Medication which is: _________________________________________________________________.

 

______________________________________________________________________________________

Signature

 

____________________________________________________________________________________

Director

 

Release of Information for Family

 

I, _____________________________________________ give Heart of Hannah permission to give any information to any of my family.

 

_________________________________________________________________________________

Signature of Client

 

_________________________________________________________________________________

Director

 

_________________________________________________________________________________

Date

 

If not then who do you want us to give information to:

 

___________________________________________________________________________________

Family Name

 

__________________________________________________________________________________

Signature of Client

 

I , ________________________________________________________ give permission to Narvis Hart to purchase groceries with my Food Stamp Card while I am a client at the Heart of Hannah.

 

________________________________________________________________

Signature of Client

 

_________________________________________________________________

Narvis Hart

 

______________________________________________________________

Date