Name

Phone

Previous Address

City

Zip

Gender
 Male Female

If female pregnant
 Yes No

Smoker
 Yes No

Marital Status
 Married Widowed Civil Union Never Married Divorced Separated Other

Race
 Native American Asian African American Native Hawaiian White/Caucasian Non-Hispanic Hispanic Unknown

Ethnicity If Hispanic
 Puerto Rican Mexican Cuban Other

Primary Language

Religious Spiritual Practice

Emergency Contact

Relationship

Emergency Contact Address

LEGAL INFORMATION / HISTORY

Pending Cases
 Yes No

Previous Involvement with the Criminal Justice System
 Yes No

Current Probation
 Yes No

Criminal Justice Contact Name

Criminal Justice Contact Phone

Number of arrests in the last 30 days

HEALTH STATUS

Psychiatric Conditions

Addiction Disorders

Medical Conditions

Trauma / Abuse

Current Health Problem

Current Health Problem
 No current health problems No known allergies

Current Provider Agency

Admission Date

Current Doctor/Clinician/Worker

Phone

Medications prescribed during current treatment

 No current medication

Do you attend AA/NA
 Yes No

Number of times attended in the last 30 days

Date of last use

What is your longest period of sobriety or stability?

DRUG / ALCOHOL HISTORY

Drug Type / Method / Days used in last 30 days / Age at first use

ENTITLEMENTS AND BENEFITS

Principal Source of Income

CurrentProbation None Public Assistance Retirement Salary Disability 

Number of People Dependent on Income

Number of Minors Dependent on Income

Benefits
 Medical SNAPSSD/SSI Other

Medicaid Status
 Active Not Active Pending Unknown Medicaid

OTHER STATE/PROVIDER AGENCY INVOLVEMENT

Are you currently working with agency or case manager or Sponsor?
 Yes No

If so, what is your worker’s name and phone number?

Name

Phone

REFERRAL SOURCE

Who referred you to this house?
 Self Treatment Center Nursing Facility Probation/Parole

FAMILY AND SUPPORTS

Do you feel you have social supports (family, friends, etc)?
 Yes No

How would you describe your current relationship with your family members?

Do any of your immediate family members have service needs?
 Yes No

If yes, please explain

Do you currently have a sponsor?
 Yes No

EMPLOYMENT STATUS

Employment Status
 Employed full-time Employed part-time Non-competitive or volunteer work Unemployed, looking for work Not in labor force

HOUSING STATUS

Living situation immediately prior to SRHS:

 Private Residence Single Room Occupancy Residential care/treatment Residential care/treatment Hospital Prison/Jail Homeless Shelter Homeless (i.e. Street)

Reason for Leaving

Have you been homeless within the last six months?

 Yes No

Are you at risk of homelessness?

 Yes No

How many of the last 30 days have you been in a controlled environment (i.e. jail, hospital, group home, etc.)?

IN THE RESIDENT OWN WORDS

I need help with the following:

 Housing Medical Care Education Hygiene Cleaning Paying Rent/Utilities Shopping & Meal Preparation Mental Health Services Substance Abuse Services Health and Wellness Services Securing Benefits Money/Debt Management Opening a Bank Account Taking Medication Legal Assistance

Are you interested in maintaining a sober lifestyle?

 Yes No Not Sure

What do you think is your biggest or most challenging issue?

What are the relapse triggers you can recognize?

What are your strengths?

What specific assistance or support would best help you to reach your goals?

Is there anything else you can tell us about yourself that would assist us in helping you meet your goals?

Staff Signature

Date

Resident Signature

Date