DH Application | Sober Living Program

Name *

First

Last

We are a Christ centered recovery residence. We Attend Church service on Sunday Evening. Is this acceptable?

If this is not acceptable for you there is no need to go any further. Thank you for looking us up and we wish you a long recovery. May God Bless you.

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Sober Date *

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Age: *

Birth Date *

Height: *

Weight: *

Eye color: *

Hair Color: *

Social Security Card? *

Do you physically have it with you? or does family member hold it for you?

Passport? *

Do you physically have it with you? or does family member hold it for you?

Valid Drivers License? *

Do you physically have it with you? or does family member hold it for you?

State ID? *

Do you physically have it with you? or does family member hold it for you?

Drivers License or ID # *

SSN: *

Emergency Contact *

First

Last

Phone *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Criminal History

Have you Been Arrested *

If so what for

Brief description crime and outcome

Misdemeanor, felony or both

Misdemeanor
Felony
Both

Sexual Offender? *

Are You on Probation? *

Name of probation officer

Phone Number and extension of officer

Medical History

All Psychiatric Diagnosis:

Medications You Are Currently Taking:

Chemical Use History: check all that apply *

Alcohol
Amphetamines
Barbiturates (Blues)
Benzodiazepine (Xanax)
Cocaine
Hallucinogens
Heroin
LSD
Marijuana
MDMA (Ecstacy/ Molly
Oxycodone
Prescription Opioids
Prescription Sedatives
Steroids

Primary Substance(s) of Preference *

Do you have withdrawal symptoms? *

Have you used in the past 72hrs? *

Can you pass a urinalysis drug screening test? *

Counseling/ Prior Treatment History:

How many times have you been in a treatment center? *

List them please

Type the names of the treatment centers you have been at starting with the last one first.

How many times have you stayed at a halfway house before? *

Paragraph Text

Type the names of the halfway you have been at starting with the last one first.

Are you seeing a counselor? *

Employment

Are you currently employed? *

Are your hours during the day or night?

Daytime hrs
Night time hrs
Don't know

How Did You Hear About Us? *

Other

Estimated Date of Entry *

Are you paying entry fee and 1st weeks rent? *

Yes
No
Someone else on my behalf

If so who?

First

Last

Family member or friend who is helping you with the finances to enter the Discipleship House?

Prescreening Mental Illness

Over the last 2 weeks, how often have you been bothered by any of the following problems? Please note, all fields are required.

Little interest or pleasure in doing things *

Not at all
Several days
More than half the days
Nearly every day

Feeling down, depressed, or hopeless *

Not at all
Several days
More than half the days
Nearly every day

Trouble falling asleep *

Not at all
Several days
More than half the days
Nearly every day

Feeling bad about yourself - or that you are a failure or have let yourself or your family down *

Not at all
Several days
More than half the days
Nearly every day

Thoughts that you would be better off dead, or of hurting yourself *

Not at all
Several days
More than half the days
Nearly every day

Feeling afraid, as if something awful might happen *

Not at all
Several days
More than half the days
Nearly every day

Do familiar surroundings sometimes seem strange, confusing, threatening or unreal to you? *

Have you heard unusual sounds like banging, clicking, hissing, clapping or ringing in your ears? *

Do things that you see appear different from the way they usually do? *

Have you felt that you are not in control of your own ideas or thoughts? *

Do you feel that other people are watching you or talking about you? *

Have you been confused at times whether something you experienced was real or imaginary? *

Have you seen things that other people can't see or don't seem to see? *

Prescreening Substance Abuse

Have you ever felt that you ought to cut down on your drinking or drug use? *

Have people annoyed you by criticizing your drinking or drug use? *

Have you ever felt bad or guilty about your drinking or drug use? *

Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover? *

What substance or addiction are you concerned about? *

Alcohol
Marijuana
Cocaine/ Crack
Heroin
Prescription Opioids
Stimulants (e.g. Speed, Meth, Prescription Stims)
Benzodiazepines (e.g. Xanax, Valium)
Other

The stress from my addiction has lead me to other mental health concerns. *

Strongly Disagree
Disagree
Somewhat Disagree
Somewhat Agree
Agree
Strongly Agree

Checkboxes

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Second Choice
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