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Application for Admission
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Application for Admission
To apply, please enter the applicant's information below.
Applicant Information
*
First Name:
Middle Initial:
*
Last Name:
*
Email Address:
Home Phone Number:
Work Phone Number:
Physical Address
*
Address
*
City
*
State
Select A State
Alabama [ AL ]
Alaska [ AK ]
Arizona [ AZ ]
Arkansas [ AR ]
California [ CA ]
Colorado [ CO ]
Connecticut [ CT ]
Delaware [ DE ]
District of Columbia [ DC ]
Florida [ FL ]
Georgia [ GA ]
Hawaii [ HI ]
Idaho [ ID ]
Illinois [ IL ]
Indiana [ IN ]
Iowa [ IA ]
Kansas [ KS ]
Kentucky [ KY ]
Louisiana [ LA ]
Maine [ ME ]
Maryland [ MD ]
Massachusetts [ MA ]
Michigan [ MI ]
Minnesota [ MN ]
Mississippi [ MS ]
Missouri [ MO ]
Montana [ MT ]
Nebraska [ NE ]
Nevada [ NV ]
New Hampshire [ NH ]
New Jersey [ NJ ]
New Mexico [ NM ]
New York [ NY ]
North Carolina [ NC ]
North Dakota [ ND ]
Ohio [ OH ]
Oklahoma [ OK ]
Oregon [ OR ]
Pennsylvania [ PA ]
Rhode Island [ RI ]
South Carolina [ SC ]
South Dakota [ SD ]
Tennessee [ TN ]
Texas [ TX ]
Utah [ UT ]
Vermont [ VT ]
Virginia [ VA ]
Washington [ WA ]
West Virginia [ WV ]
Wisconsin [ WI ]
Wyoming [ WY ]
*
Zip Code
Applicant Identification
*
Social Security Number
*
Citizenship
Date of Birth
*
Ethnicity
*
Gender
Emergency Contact
*
Emergency Contact
*
Emergency Phone
Emergency Address
*
Address
*
City
*
State
Select A State
Alabama [ AL ]
Alaska [ AK ]
Arizona [ AZ ]
Arkansas [ AR ]
California [ CA ]
Colorado [ CO ]
Connecticut [ CT ]
Delaware [ DE ]
District of Columbia [ DC ]
Florida [ FL ]
Georgia [ GA ]
Hawaii [ HI ]
Idaho [ ID ]
Illinois [ IL ]
Indiana [ IN ]
Iowa [ IA ]
Kansas [ KS ]
Kentucky [ KY ]
Louisiana [ LA ]
Maine [ ME ]
Maryland [ MD ]
Massachusetts [ MA ]
Michigan [ MI ]
Minnesota [ MN ]
Mississippi [ MS ]
Missouri [ MO ]
Montana [ MT ]
Nebraska [ NE ]
Nevada [ NV ]
New Hampshire [ NH ]
New Jersey [ NJ ]
New Mexico [ NM ]
New York [ NY ]
North Carolina [ NC ]
North Dakota [ ND ]
Ohio [ OH ]
Oklahoma [ OK ]
Oregon [ OR ]
Pennsylvania [ PA ]
Rhode Island [ RI ]
South Carolina [ SC ]
South Dakota [ SD ]
Tennessee [ TN ]
Texas [ TX ]
Utah [ UT ]
Vermont [ VT ]
Virginia [ VA ]
Washington [ WA ]
West Virginia [ WV ]
Wisconsin [ WI ]
Wyoming [ WY ]
*
Zip Code
Guardian Contact
Guardian Contact (optional)
Guardian Phone
Guardian Address
Address
City
State
Select A State
Alabama [ AL ]
Alaska [ AK ]
Arizona [ AZ ]
Arkansas [ AR ]
California [ CA ]
Colorado [ CO ]
Connecticut [ CT ]
Delaware [ DE ]
District of Columbia [ DC ]
Florida [ FL ]
Georgia [ GA ]
Hawaii [ HI ]
Idaho [ ID ]
Illinois [ IL ]
Indiana [ IN ]
Iowa [ IA ]
Kansas [ KS ]
Kentucky [ KY ]
Louisiana [ LA ]
Maine [ ME ]
Maryland [ MD ]
Massachusetts [ MA ]
Michigan [ MI ]
Minnesota [ MN ]
Mississippi [ MS ]
Missouri [ MO ]
Montana [ MT ]
Nebraska [ NE ]
Nevada [ NV ]
New Hampshire [ NH ]
New Jersey [ NJ ]
New Mexico [ NM ]
New York [ NY ]
North Carolina [ NC ]
North Dakota [ ND ]
Ohio [ OH ]
Oklahoma [ OK ]
Oregon [ OR ]
Pennsylvania [ PA ]
Rhode Island [ RI ]
South Carolina [ SC ]
South Dakota [ SD ]
Tennessee [ TN ]
Texas [ TX ]
Utah [ UT ]
Vermont [ VT ]
Virginia [ VA ]
Washington [ WA ]
West Virginia [ WV ]
Wisconsin [ WI ]
Wyoming [ WY ]
Zip Code
Logistics
Living Situation (Where and with whom does the applicant live)?
How would applicant be transported to and from the H.E.A.R.T. facility?
Referring Agency
Agency
Case Manager
Residential Facility
Facility Phone
Resident Case Manager
Case Manager Phone
Medical Information
Diagnosis
Diagnosis Date
Please provide a copy of applicant's diagnosis.
Does applicant have any Physical disabilities?
List all medications taken by applicant and time of day taken.
If medications taken, can applicant take his/her own medications?
Does the applicant have any Limitations that would interfere with the full participation of this program?
Does the applicant need any special equipment or considerations?
Does the applicant need any special Dietary needs?
What is the applicant's favorite food?
What is the applicant's least favorite food?
Does the applicant have any additional Social Limitations we must be aware of?
Has applicant ever participated in a residential substance abuse rehabilitation program? If yes, name of facility, and starting and ending dates of participation.
Has applicant ever participated in an out-patient substance abuse rehabilitation program? If yes, name of facility, and starting and ending dates of participation.
If applicable, number of months of sobriety.
Benefits
Applicant Benefits
Please check all that apply. You will be required to provide proof of benefits, such as an award letter or copy of card.
Referral Source
How did you hear about the H.E.A.R.T. Program?
If "Other" selected, please explain.
Referred By Whom
Applicant Employment
Employer
Responsibilities
Start Date
End Date
Education
Education
Number of Years?
School Name
Highest Level Completed
Dates of Attendance
Comments and Suggestions
This is a comment box.
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