Application for Admission s3

Mary’s House 520 Guilford Avenue Greensboro, NC 27401 336.275.0820

APPLICATION FOR ADMISSION

IDENTIFYING DATA

Name: ______(LAST) (FIRST) (MIDDLE)

Other Names Used: ______

Age: _____ DOB: ______SSN: ______Ethnicity: ______MM/DD/YY

Referral Information (Select all that apply): Friend Relative Caseworker Counselor Treatment Center Shelter Prior Applicant

Name of referring individual: ______Relationship to you: ______Phone No. ______OTHER INFORMATION

Have you ever sought prior help for your alcohol/drug problem? Yes No If yes, please list the treatment centers below with the most recent admission first.

Name/Location of Dates of admission Type of facility Did you complete the How long did you stay sober after you finished the Program and discharge (DUI, outpatient, program? program? residential) Yes No SUBSTANCE ABUSEYes No HISTORY Yes No Yes No SUBSTANCE AGE AT AGE WHEN # OF TIMES AMOUNT USUAL WAY DATE OF # OF TIMES FIRST USE REGULAR USEDHEALTH PER USED EACH USED (Oral, LAST USE USED IN How is your overall health now? EXCELLENTUSE BEGAN GOODWEEK FAIRTIME (If no POORSmoking, PAST 30 use in past year, Inhalation, DAYS Do you have any chronic health problems? Yes No If yes, please specify: ______describe period Injection) of heaviest use) AreAlcohol you pregnant? (Beer, Yes No If yes, when is your due date? ______Wine, Hard Liquor) Nicotine Are you currently having any physical problems? Yes No If yes, please specify: ______(Cigarettes, Cigars, Chewing tobacco, AreSnuff) you currently under a doctor’s care? Yes No If yes, PERSONALplease indicate why: DATA ______Marijuana What prescription medications are you currently taking? ______MaritalCocaine/Crack Status: Single Married Separated Divorced Widowed Living as married What over-the-counter-medications are you currently using or taking regularly? ______If married,Caffeine husband’s (coffee, name: ______soft drinks, No- Address:AreDoze, you allergic______Red Bull) to any foods or medications? Yes City:No If ______yes, please specify what ______State: ______Zip Code: ______Amphetamines How(Meth, many Ecstasy, times have you been to the ER in the past year? ______Date of last visit: ______Reason: ______Do you rent/own the above residence? Yes No Currently homeless? Yes No Being evicted? Yes No Date of eviction: ______speed) Most recent hospitalization: Where ______Date ______Reason: ______HomeSedative- Phone: ______Cell Phone: ______Other number where: ______Hypnotic/Anxiolytic we can reach you CHILDREN:HaveBenzodiazepines you ever received help for a mental or emotional problem? Yes No If yes, when and where was the treatment? ______(Xanax, Valium) 1.______Name:Tranqulizers, ______Age: ______DOB: ______Male Female Quaaludes MM/DD/YY DoHeroin you or any of the children who will be living with you at Mary’s House have any health issues or specific health care needs? Yes No If yes, please Legal Custody Yes No Current living with You Father Grandparent(s) Other relative(s) Foster parent(s) Opioids (Vicodin, explainPercocet, ______Codeine, 2. Name: ______Age: ______DOB: ______Male Female Oxycontin, MM/DD/YY Demerol, LEGAL HISTORY Methadone Legal Custody Yes No Current living with You Father Grandparent(s) Other relative(s) Foster parent(s) HaveBarbiturates you ever been arrested? Yes No If yes, what were the charges (be specific)? (Nembutal, Seconal, 3. Name: ______Age: ______DOB: ______Male Female YearPhenobarbital) ______Charge ______Inhalants (Paint, MM/DD/YY Yearglue, ______gasoline, Charge ______aerosols)Legal Custody Yes No Current living with You Father Grandparent(s) Other relative(s) Foster parent(s) YearHallucinogens ______Charge ______Use(LSD, additional PCP, sheets if necessary. YearPsilocybin/Shrooms ______Charge ______Do anyMescaline/Peyote) of your children have special needs? ______HaveOTHERS you ever been convicted of anything other than a minor traffic offense? Yes No If yes, please list all convictions. EDUCATION: PATTERN OF USE FOR ALCOHOL Daily Periodic Weekends Binges Alone With others Other: ______WhatYear is ______your total number of yearsCharge of ______education completed? ______High school Disposition diploma/GED? (time in jail/prison,Yes Noprobation)______PATTERN OF USE FOR OTHER DRUGS Daily Periodic Weekends Binges Alone With others Other:______DoYearProblems you ______have a withhistory use of learning(Check Charge problems all ______that (ADD/AD/HD apply): Need or special increasing education)? amounts DispositionYes of Noalcohol (time in or jail/prison, other drugs probation)______(tolerance) Blackouts Binges Overdoses Withdrawal Legal Work/School Financial Family/Marital/Relationships Child EMPLOYMENT:YearAbuse/Neglect ______Poor Charge health ______Failed attempts to stop or reduce Disposition use (time in jail/prison, probation)______Most recent job: ______Type of job: ______Year ______Charge ______Disposition (time in jail/prison, probation)______Are What you interested is the longest in additional period education of time or thatjob training? you have Yesgone withoutNo If yes, using list the alcohol type. ______or other drugs? ______Use additional sheets, if necessary. ListIf youryou careerare not goals: using ______drugs now, how long have you been sober? ______Do you have any pending criminal charges? Yes No If yes, please specify the charges: ______

______Have you ever been to an AA or NA meeting? Yes No

AreAre you you currently attending on probation AA or or NA parole? now? YesYes No No If yes, indicate which: Probation Parole County ______

HowWhat much brings time doyou you into have treatment left? ______at this time? Please______list probation/parole officer’s name and number: ______If you have an attorney, please list the name and number: ______ATTACHMENT

Please use the space below to explain why you believe that living at Mary’s House would be important to your recovery.

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