Are your children 9 years old or younger?
*
Are you currently pregnant?
*
Are you a convicted sex offender?
*
Are you currently on prescribed Suboxone?
*
Have you been diagnosed with Paranoia Schizophrenia and/or Multiple Personality Disorder (DID)?
*
Do you have a disability that requires a cane, walker or wheelchair?
*
Name
*
First Name
Last Name
Maiden name or aliases
First Name
Last Name
Date of birth
*
Must be over 18 years old
MM
DD
YYYY
Social Security #
*
Email
*
Phone
(###)
###
####
Preferred method of contact:
*
Current Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Previous address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Length of residency:
Current living situation?
Are you currently safe?
*
Yes
No
Are you a US citizen?
*
Emergency contact name:
*
First Name
Last Name
Emergency contact phone
*
(###)
###
####
Emergency contact relationship:
*
Name of facility:
Representative’s name and contact information:
Date of admission:
MM
DD
YYYY
Anticipated release date:
MM
DD
YYYY
Do you currently have a copy of the following:
*
Choose all that apply
Have you served in the United States military?
*
Are you currently enlisted in the United States military?
*
If yes, what branch?
Years of service
E.L.I. 's House is a Christ-Centered faith-based program. Where do you see yourself spiritually?
*
Have you ever been exposed to or participated in witchcraft or wicca activities?
*
If YES, please explain:
Please provide the information below for all medications you are currently taking or prescribed.
Please follow format below:
I agree to give E.L.I.’s House written permission to verify all medications listed and their associated prescriber:
Sign your name in box below:
*
By typing your name below, you acknowledge and agree that this serves as your electronic signature, confirming the accuracy of the information provided.
First Name
Last Name
Hepatitis A
*
Hepatitis B
*
Hepatitis C
*
Tuberculosis (TB)
*
HIV/AIDS
*
History of Seizures
*
Please list any other health diagnoses not listed above (Chronic diseases or illness):
*
Please list all Allergies:
*
Cooking
*
Dusting
*
Laundry
*
Mopping
*
Vaccuming
*
Gardening
*
Barn/Outdoor Chores
*
Chicken Care
*
Lifting 50 Ibs
*
If you are unable to perform any of the above, please indicate the reason why:
Do you have any physical disabilities NOT requiring the assistance of a Cane, Walker or Wheelchair:
*
If "YES," please explain below:
Health Insurance Provider:
Policy Number:
Dental Insurance Provider:
Policy Number:
Behavioral Health Insurance Provider:
Policy Number:
Anxiety
*
Depression
*
Bipolar
*
D.I.D.
*
Antisocial Personality Disorder
*
PTSD
*
Borderline Personality Disorder
*
Schizophrenia
*
OCD
*
Eating Disorder
*
Suicidal Ideation
*
List any other mental Health diagnoses not listed above:
Have you ever had thoughts of hurting yourself and/or others?
*
If yes, when was the last time you experienced these thoughts?
Does anyone in your family have a history of mental health illness?
*
Name of family member diagnosed:
Mental health illness:
Name of family member diagnosed:
Mental health illness:
Name of family member diagnosed:
Mental health illness:
Case Management
*
Provider Name:
Counseling
*
Provider Name:
Hospitalization
*
Where?
When?
Inpatient Treatment
*
Provider Name:
Outpatient Treatment
*
Provider Name:
Mobile Crisis
*
Provider Name:
Mental Health Court
*
Where?
Have you ever used alcohol?
*
At what age was your first drink?
Do you feel you're addicted to alcohol?
*
Have you ever been in treatment for alcohol abuse?
*
If so, how many times?
Please include the
name of your most recent treatment facility
Did you complete the treatment?
If "NO", why not?
Does anyone in your family have a history of alcohol abuse?
*
Have you ever done any 12 step work?
*
Have you ever abused drugs?
*
Do you feel like you are addicted to drugs?
*
Please provide the information below for all drugs you have used:
Include (1) drug name, (2) method of administration, (3) age of first use, (4) frequency of use, (4) quantity used, (5) date last used, and (6) longest period clean.
Have you ever been in a drug treatment or recovery program?
*
If "Yes", how many times?
Please provide the name of your most recent treatment facility:
Did you complete the treatment?
If "No", why?
Does anyone in your family have a history of drug abuse?
*
Are you willing to consent to drug screening prior to admission as well as during the program:
*
Are you willing to go to detox, if necessary, prior to admission:
*
Do you currently use tobacco or nicotine products?
*
If "Yes", would you be willing to stop using tobacco or nicotine products?
Have you ever been a victim of domestic violence?
*
Have you ever been a perpetrator of domestic violence?
*
Have you ever been a victim of sexual assault, rape, or incest?
*
Have you ever been perpetrator of sexual assault, rape, or incest?
*
Does anyone in your family have a history of domestic violence?
*
Are you currently on probation or parole?
*
If "Yes", for what charges?
Do you have any community service hours?
*
If "Yes", number of hours per week/month?
Probation Officer:
Probation Office:
Probation office phone #
(###)
###
####
Do you have any current charges?
*
If "Yes", what are the charges:
Do you have any pending charges?
*
If "Yes," in what county and state?
Court date(s):
Do you have any possible outstanding warrants?
*
Have you ever been convicted of a violent crime?
*
Have you ever been convicted of arson?
*
Have you been convicted of a felony?
*
If "yes", please list all charges:
Are you currently incarcerated?
*
If "yes," list DOC#, location, and release date:
List the 5 most recent convictions/charges:
Include (1) date of charge, (2) county charge, (3) outcome/sentencing
What is the highest level of education you have completed?
*
If you did not complete high school, do you have a GED?
*
If "No", are you interested in obtaining your GED?
*
What is the name of the last school you attended?
*
What city and state is it in?
*
Checking Account?
*
Debit Card?
*
Savings Account?
*
WIC
*
Amount:
SNAP Benefits
*
Amount:
Families First
*
Amount:
Supplemental Security Income (SSI)
*
Amount:
Social Security Disability Income (SSDI)
*
Amount:
Child Support
*
Amount:
Other:
Relationship Status:
*
Married
Divorced
Single
Seperated
Widowed
In relationship
How do you feel about giving up romantic relationships for the duration of your recovery program?
Are you currently pregnant?
*
Due Date
*if applicable*
MM
DD
YYYY
Have you ever had an abortion?
*
Are you currently on any contraceptive?
*
If yes, what?
Do you have parental rights to at least one of your children?
*
How many children would you have coming with you to E.L.I’s House?
*
Child's Name
First Name
Last Name
Birthday
MM
DD
YYYY
Sex
Male
Female
Status of custody:
List any allergies:
Medications
List all of your child's medications and the reason they were prescribed
Child's Name
First Name
Last Name
Birthday
MM
DD
YYYY
Sex
Male
Female
Status of custody:
List any allergies:
Medications
List all of your child's medications and the reason they were prescribed
Child's Name
First Name
Last Name
Birthday
MM
DD
YYYY
Sex
Male
Female
Status of custody:
List any allergies:
Medications
List all of your child's medications and the reason they were prescribed
Child's Name
First Name
Last Name
Birthday
MM
DD
YYYY
Sex
Male
Female
Status of custody:
List any allergies:
Medications
List all of your child's medications and the reason they were prescribed
How do you feel about a 2 year commitment?
*
How do you feel about living in a community setting?
*
How do you feel about the necessary rules and restrictions as a resident?
*
What are your expectations of E.L.I.’s House?
*
What are your concerns about moving to E.L.I.’s House?
*
Why would you like to be considered for residency in our program?
*
Are you willing to participate in employment, volunteering, education courses and all other faith-based activities offered?
*
Is this your first time applying to become a guest @ E.L.I.’s House?
*
How did you hear about E.L.l’s House?
*
Friend
Family
Internet Search
Church
Another Organization
Medical Facility/Practitioner
Other
Name of Referral (if applicable):
I personally completed this application without assistance or input from others. I confirm all information to be true and accurate. I authorize E.L.I.’s House to use the information I provided to make a decision regarding my acceptance into this program.
*
Today's Date
*
MM
DD
YYYY
I understand job opportunities are offered but not guaranteed. If I am accepted, I agree to follow all program guidelines. Upon admission, I agree to sign the resident handbook containing behavioral agreements, policies, and procedures as well as an updated release of information.
*
Today's Date
*
MM
DD
YYYY
I understand that alcohol and drug screenings will be conducted prior to admission and consistently during residency. I agree to complete these screenings upon request and understand that testing positive for alcohol or drugs could result in discharge from the program.
*
Today's Date
*
MM
DD
YYYY
