O.U.R. House, Inc. .
Admission Referral Form
Name / Agency / address of Person Making Referral:
Phone Number: Date Referral Received:
Interview Scheduled: on phone _______in person _______
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Potential Resident Information
Name: ___________________ Date of Birth: ( age )Social Security # __________
Race: White _____Black _____ Other _____________________
Veteran Status: _____________________ Are you Pregnant? Or could you be? ____________________
Marital Status: ___ Never Married ___Married and Living with spouse ___Widowed
___Divorced/Annulled ___Separated How many marriages? ___
Children: (names, ages, contact) ________________________________________________________
____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Employment Status? (circle one) Not employed Yes, part-time No, retired
Yes, Full-time Yes, odd jobs Other: ____________________________________________
Most recent occupation? (e.g. secretary, machinist) ___________________________________________
Employer: (name/address/phone): _________________________________________________________
_____________________________________________________________________________________
Food Stamp Allotment: ___________ Medicaid? _#________________ Insurance? _________________
Income: $___________ weekly — monthly — yearly? (circle one)
Source of Income: _____________________________________________________________________
Rent is $250.00 / monthly and 1st month must be paid at admission. This includes utilities and food.
Source of ability to Pay Rent:_____________________________________________________________
Educational level: circle highest grade completed:
Elementary: 0 1 2 3 4 5 6 7 8 High School: 9 10 11 12 GED College: 13 14 15 16 Post Graduate: yes - no
Current living situation:
_____________________________________________________________________________________
_____________________________________________________________________________________
Valid Driver’s License? ___If yes #__________ Vehicle?: ____License # _____________Insurance? ___
Photo ID? Birth Certificate? Soc.Sec. Card ? .
Emergency Contact: ___________________ Phone: _________________ Relationship: _____________
Address: .
Alcohol / Drug Use History:
____________________________________________________________________________________________
____________________________________________________________________________________________
______________________________________________________________________
In the last six months, what is the longest period of abstinence? : ________________________________
Have you been in a substance abuse treatment program, either in-patient or out-patient in the past three
years? _______________________
Give name, dates and reason for leaving:
_____________________________________________________________________________________
___________________________________________________________________________________
Do you currently attend 12 step program meetings? ______ AA or NA or Both? ___________________
How many meetings do you attend each week? _______________
Do you have a sponsor? _______
Are you facing any legal charges? Yes___ No If yes, explain what they are and give any court dates.
_____________________________________________________________________________________
Are you on probation or parole? Yes No If yes, for what and who is your PO.?
____________________________________________________________________________________
Have you ever been convicted of a felony?: ____ If yes, please explain:__________________________
Have you ever been convicted of a violent crime?: ____ If yes, please explain:__________________________
____________________________________________________________________________________
Have you ever been charged or convicted of a sexual offence? _____ If yes, please explain:
____________________________________________________________________________________
Are you required to register with the state as a sexual offender? ________
How is your health? _________________________________________________________________
Medications currently prescribed: [will not be accepted if taking controlled substances, ie: Benzodiazepines, Narcotics, etc.]
Name Dose Prescribed by
____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Do you have a primary care physician? ____ If yes, list doctor’s name - phone - address.
____________________________________________________________________________________
Do you have any appointments, court dates, etc. scheduled? ____ If yes, when, where and with whom?
____________________________________________________________________________________
____________________________________________________________________________________
Important contacts: CPS worker:
.
Drug Court:
.
DHHR Service worker:
.
OTHER:
.
Areas of concern Yes / No notes:
a Mental Illness
b Alcohol Abuse
c Drug Abuse
d HIV/AIDS / Hep C and related diseases
e Developmental Disability
f Physical Disability
g Domestic Violence
h Other - please specify
By signing below, I certify that the information provided in this interview is true and accurate. I understand and
agree to if accepted as a resident of OUR House I will abide by all rules and regulations of OUR House, Inc. I
understand I may not be accepted for residency if I am prescribed a controlled substance, i.e. Opiates,
Benzodiazepines, or Amphetamines. I understand that I will be subject to immediate expulsion if any of the
following occur: 1. I use or bring into the house alcohol or any illicit drug. 2. I engage in disruptive behavior.
3. I fail to pay my rent. I understand if I am evicted from the house or leave voluntarily without giving at least a
two week notice, I will forfeit all rent money paid.
Signature: ______________________________________________ Date ________________
Witness Signature: ________________________________________ Date _______________
07/27/11