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Application for Admission

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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

*	Zip Code

Applicant Identification

Social Security Number

Citizenship

Date of Birth

Ethnicity

Gender

Emergency Contact

Emergency Phone

Emergency Address

*	Address

*	City

*	State

*	Zip Code

Guardian Contact

Guardian Contact (optional)

Guardian Phone

Guardian Address

	Address

	City

	State

	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

Number of Years?

School Name	Highest Level Completed	Dates of Attendance

Comments and Suggestions

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