Growth Home Application
Personal Information
Name
Date of Birth
Spouse Name
Are you homeless?
Yes
No
Address
Home Phone Number
Cell Phone
Work Phone
Age
Sex
Male
Female
Height
Weight
Religion
Race/Ethnicity
Marital Status
Single
Married
Divorced
Widowed
Emergency Contact Name
Relationship
Emergency Phone Number
Secondary Number
Emergency Address
Do you have health insurance?
Yes
No
Please provide your provider name, provider phone number, policy number, and group number.
Do you have dental insurance?
Yes
No
Please provide your provider name, provider phone number, policy number, and group number.
Do you have a car?
Yes
No
Who is taking care of your car while you are in the program?
Are you currently receiving any type of income?
Yes
No
Please explain:
Have you ever been in the military?
Yes
No
Were you discharged?
Yes
No
If dishonorable discharge please explain:
Education
What is the last year of school you completed?
Primary: 1
Primary: 2
Primary: 3
Primary: 4
Primary: 5
Primary: 6
Primary: 7
Primary: 8
Primary: 9
Primary: 10
Primary: 11
Primary: 12
College: 1
College: 2
College: 3
College: 4
College: 4+
Can you read and write English?
Yes
No
Can you speak English?
Yes
No
Have you ever been in special education classes?
Yes
No
Religious Background
Do you believe in God?
Yes
No
Uncertain
Have you ever accepted Jesus Christ as your savior?
Yes
No
Uncertain
Are you attending a church now?
Yes
No
What church are you attending?
Legal History
Have you ever been arrested?
Yes
No
Please indicate how many times and provide details:
Have you ever done jail time?
Yes
No
What for and how long did you do jail time?
Are you on probation or parole?
Yes
No
Please give probation or parole officer's contact information below:
Are you court ordered to be here?
Yes
No
Please provide contact information regarding your court case:
Do you have any legal charges pending?
Yes
No
Where are the charges and what are the charges?
Do you think you may have any outstanding warrants?
Yes
No
If yes, please explain:
Do you have any other legal matters that would require you to attend to in the next 90 days?
Yes
No
If yes, give details below:
Drug History
Have you ever used drugs?
Yes
No
If yes, how old were you?
Why did you try them?
To help me deal with life
To escape reality
To fit in with my peers
My friends use drugs
To make emotional pain go away
Some of my family use drugs
Just for fun
I was bored
Curiosity
Other:
Have you ever sold drugs?
Yes
No
Do you think you have a problem with drug use?
Yes
No
Uncertain
Explain why or why not:
Since you've been using, what's the longest period of time that you've been sober?
Please fill out information below concerning drug use.
First Time (How old were you or what month/year)
Last Time (Approximate date)
Frequency (How often did you use: occasionally, monthly, weekly, daily, etc.)
Amount Used (How much did you use per day/week/month)
Alcohol
Barbiturates
Benzodiazepines
Cocaine/Crack
Glue/Paint
Heroin
Inhalants (Snuffing)
LSD
Marijuana
MDMA (Ecstacy)
Meth
Mushrooms
PCP
Prescription Drugs
Speed
Tobacco
Medical History
Date of last physical exam:
Results of last physical exam:
List any physical ailments or handicaps that you may have:
Date of last dental exam:
Results of last dental exam:
List any dental problems you may have:
Date of last eye exam
Results of last eye exam:
Do you wear glasses?
Yes
No
Do you wear contacts?
Yes
No
List anything that you may be allergic to:
Have you ever been diagnosed with ADD?
Yes
No
When was your diagnosis?
Have you ever been diagnosed with ADHD?
Yes
No
When was your diagnosis?
Have you ever been diagnosed with any mental disorder?
Yes
No
When was your diagnosis?
Have you ever been diagnosed with Tuberculosis?
Yes
No
When was your diagnosis?
Have you ever been diagnosed with Hepatitis A?
Yes
No
When was your diagnosis?
Have you ever been diagnosed with Hepatitis B?
Yes
No
When was your diagnosis?
Have you ever been diagnosed with Hepatitis C?
Yes
No
When was your diagnosis?
Have you ever been diagnosed as HIV Positive?
Yes
No
When was your diagnosis?
Have you ever been diagnosed with AIDS?
Yes
No
When was your diagnosis?
Have you ever been diagnosed with Herpes?
Yes
No
When was your diagnosis?
Have you ever been diagnosed with any STD?
Yes
No
When was your diagnosis?
Have you ever been diagnosed with Body Lice?
Yes
No
When was your diagnosis?
Have you ever been diagnosed with high blood pressure?
Yes
No
When was your diagnosis?
Have you ever been diagnosed with a heart attack/disease?
Yes
No
When was your diagnosis?
Have you ever been diagnosed with cancer?
Yes
No
When was your diagnosis?
Have you ever been diagnosed with any stomach disorder?
Yes
No
When was your diagnosis?
Have you ever been diagnosed with diabetes?
Yes
No
When was your diagnosis?
Have you ever been diagnosed with a stroke?
Yes
No
When was your diagnosis?
Have you ever been diagnosed with any other illness?
Yes
No
Please list other diagnosis' and when your were diagnosed.
Are you prone to seizures?
Yes
No
Do you currently have any chronic medical conditions not listed above that require regular doctor visits?
Yes
No
If yes, please explain:
Are you presently on any medication?
Yes
No
If yes, please list below and give reason for taking it:
Have you ever been admitted to a hospital?
Yes
No
If yes, please explain:
Are you physically able to perform all assignments (you must be able to life 25 lbs, be able to stand for long periods of time, as well as climb up 4 flights of stairs) as part of this program?
Yes
No
If no, please explain:
Have you ever had any type of counseling?
Yes
No
If yes, please state how long and for what purpose?
Have you ever been diagnosed with any type of mental condition?
Yes
No
If yes, please explain:
Have you ever been under psychiatric care or been admitted to a mental health institution?
Yes
No
If yes, please explain:
Sexual History
Are you sexually active?
Yes
No
At what age did you become sexually active?
How many sexual partners have you had?
Have you ever had unprotected sex?
Yes
No
Have you ever contracted a sexually transmitted disease?
Yes
No
If yes, please list disease(s), when, and how it was treated:
Have you ever been the victim of sexual abuse?
Yes
No
If female, are you currently pregnant?
Yes
No
Uncertain
Have you been pregnant in the past?
Yes
No
Uncertain
If yes, what was the result of the pregnancy?
Birth
Miscarriage
Abortion
Stillborn
Do you have any children?
Yes
No
If yes, how many and what are their ages?
If male, are you the father of any children?
Yes
No
Uncertain
If yes, how many and what are their ages?
Have you ever been involved in prostitution?
Yes
No
Have you ever been involved in any homosexual behavior or activities?
Yes
No
Do you consider yourself to be:
Heterosexual (Straight)
Homosexual (Gay/Lesbian)
Bisexual
Other:
Goals
What goals do you have while in this program?
What do you want to happen in your life while you are in this program?
How did you hear about our Growth Home program? (Check all that apply)
Friend
Family Member
Church Leader
Brochurre/Flyer
Social Media
Other:
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