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HOPE FOR PRISONERS

INTAKE FORM

 
PARTICIPANT INTAKE/REGISTRATION FORM
 
 
PERSONAL INFORMATION:
 
 
EMERGENCY CONTACT:
 
“List two (2) emergency contacts. Include first name, last name, relationship, and phone number.”
 
 
DEMOGRAPHIC INFORMATION:
 


 

 

 
VETERAN STATUS:
 
 
HOUSING INFORMATION:
 

Do you reside in any of the following:
Sober Living House/ Transitional Living/ Assisted Living/ None

Name of facility/ house:
Date of entry:
Name of house manager:
Phone number of house manager:
 
 
List up to four (4) household members. Include Name, relationship, gender, and age.
 
 
List up to three (3) children not living with you. Include gender and age.
 
FAMILY/HOUSEHOLD INFORMATION:
 

 

 
EDUCATION:
 

List when and where you attended the following, include the major and if you graduated: High school, College/ University, Graduate School, Vocational/ Other Schooling.
 
HISTORY:
 
Date of last use, amount, and number of years of alcohol abuse.

 

Drug of choice, other drugs used, date of last use, number of years used.

 

List all medications with doctor. 

 


List any additional information you think is important regarding your medical history.

 

List any previous inpatient and/or drug- alcohol rehab hospitalizations.

 

 
CHARGES/CONVICTIONS
 



 

 



 
EMPLOYMENT:


 

List the last three (3) previous jobs. Include employer, job title, and length of employment.
 
 
INTERESTS / HOBBIES:
 
 
GOALS/EXPECTATION:
 
 
ADDITIONAL INFORMATION:
 
 
TRANSITIONAL CHALLENGES YOU HAVE ENCOUNTERED