WOMEN RESIDENCY INTAKE FORM

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					                    SAMPLE WOMEN’S RESIDENCY INTAKE FORM – BENEVOLENCE SUPPORT SERVICES, LLC


Modify this sample form as needed.
                                     WOMEN’S RESIDENCY INTAKE FORM
                                      (Agency Name – Address – Phone)
                You can be denied acceptance or terminated for any false or omitted information.

 General Profile:                                                                        Date: ________________

 Full Name: ____________________________________________ D.O.B.______________ Age: ________________

 S.S.N. ________________ Picture ID Type: _______________________________________

 Are you willing to commit to a full day of classes and work? Yes/No?

 Do you willingly submit to authority? Yes/No?

 What is your Race? (You may circle more than one race)

     American Indian/Alaskan Native, Asian, White, Native Hawaiian/Other Pacific Islander, Black/African American,

     Other: ___________________

 Are you Hispanic or Latino? __________

 Have you ever served on active duty in the U.S. Military? Yes/No?

 Current Address: ________________________________________________________________________________

 Previous Address: _______________________________________________________________________________

 Phone: ___________________________

 Homeless? Explain: ______________________________________________________________________________

    ___________________________________________________________________________________________

 Married? Yes/No? If Yes, husband’s full name: ___________________________________

 If married, how long? ___________

 Do you have children? Yes/No? If Yes, how many? _____

                     Name/boy or girl            Age         Custody of            Relationship




 Mother Living? Y/N? If yes, provide full name: _____________________________________

 Mother’s Ph.# ___________________ Do you keep contact with her? Yes          No

 Father Living? Y/N? If yes, provide full name: _____________________________________

 Father’s Ph.# ___________________ Do you keep contact with him? Yes          No

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                       SAMPLE WOMEN’S RESIDENCY INTAKE FORM – BENEVOLENCE SUPPORT SERVICES, LLC




Do you have an intimate boyfriend or girlfriend? Yes                No

    If Yes, provide full name: _______________________________ Phone # _________________

Are you or have you ever been engaged in same sex activities?                 Yes      No

Do you have any on-going relationship that would interfere with focusing on your recovery? Yes/No?

Comments: ____________________________________________________________________________________

NOTE: Men other than husbands, fathers and sons will not be permitted to visit. There are no exceptions to this rule. An infraction
against this rule is grounds for dismissal from the program.

What is your religious background? _________________________________________________________________

    __________________________________________________________________________________________

Education Level: _______________________________________________________________________________

Special Ed.: ___________________________________________________________________________________

Would you be interested in furthering your education? Yes                     No

    If yes, which of these would you want to pursue? (GED, Trade, College)

What are your personal goals for the immediate future? _________________________________________________

    __________________________________________________________________________________________

How can we help you in reaching your goals? _________________________________________________________

    __________________________________________________________________________________________

Why do you feel you are ready for recovery now? _____________________________________________________

    __________________________________________________________________________________________

What are your strengths? _________________________________________________________________________

    __________________________________________________________________________________________

What are your weaknesses? ______________________________________________________________________

    __________________________________________________________________________________________



Criminal History:
If we run a background check on you, what would we find? Explain: ________________________________________

    ___________________________________________________________________________________________

Do you have any outstanding warrants? Yes/No? If Yes, explain: _________________________________________

    ___________________________________________________________________________________________

Do you have pending court dates? Yes/No? If Yes, when: ________________________________________________
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                     SAMPLE WOMEN’S RESIDENCY INTAKE FORM – BENEVOLENCE SUPPORT SERVICES, LLC




NOTE: All court appearances must be completed before admission to our program.

Are you on probation? Yes/No? ___________ If Yes, for what offence? _____________________________________

    What is the length of your probation? _________

If you are currently incarcerated, when is your expected release date? __________________


*Medical: Note: Before entering into this program, each client must be stable with medication.
Do you have a disabling condition? (You may circle more than one)

    Physical, Developmental, Mental Health, HIV/AIDS, Drug or Alcohol Addiction, Chronic Health Condition

    Explain: ___________________________________________________________________________________

    __________________________________________________________________________________________

Are you currently taking medications for this?     Yes         No

    If Yes, what is the medication? _________________________________________________________________

Do you have any special food or dietary needs? Yes               No

    If Yes, explain. ______________________________________________________________________________

    __________________________________________________________________________________________

Have you been tested for STD’s (HIV, RPR, TB, etc.)? Yes No If Yes, what were the results?
   _________________________________________________________________________________________

    _________________________________________________________________________________________

    If yes, when? ________________ If Yes, where? __________________________________

Do you have Hepatitis C?       Yes       No

Have you ever had a mental health evaluation? Yes                No        If Yes, when? _________________

    If Yes, what was the diagnosis? _________________________________________________________________

    Doctor(s) name: _____________________________________________________________________________

    What medications were you prescribed? _________________________________________________________

    __________________________________________________________________________________________

    Are you taking your prescribed medications?        Yes          No

Do you take any over-the-counter medications?         Yes         No         If Yes, what are they for?

    __________________________________________________________________________________________

Have you thought about or tried to commit suicide? Yes                No         If yes, explain when and what happened?

    __________________________________________________________________________________________
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                       SAMPLE WOMEN’S RESIDENCY INTAKE FORM – BENEVOLENCE SUPPORT SERVICES, LLC




    __________________________________________________________________________________________

    Did these thoughts of suicide coincide with drug use?               Yes      No

    Do you still have thoughts of suicide?         Yes        No

Do you smoke or chew tobacco?            Yes         No

Do you have body piercings?          Yes        No            If Yes, where? _______________________________________

Do you have tattoos?        Yes        No         If Yes, where? _______________________________________________

Note: Body piercing, tattoos, and extreme hair color will not be allowed while in this recovery program. This is a women’s facility - only
female attire is acceptable. No male attire or skimpy dressing is acceptable.

Do you have any dental needs?            Yes         No

    If Yes, explain. ______________________________________________________________________________

    __________________________________________________________________________________________

Are you or could you possibly be pregnant?            Yes          No

(We are sorry that we cannot accept women who are pregnant at this facility.)

Are you able to climb up and sleep on a top bunk?             Yes         No

    If No, explain? ______________________________________________________________________________

    __________________________________________________________________________________________

If we were to drug test you today, what would we find? __________________________________________________

    Drugs Abused: ______________________________________________________________________________

    How long using? ___________ Last used: ___________ Longest sober/clean: ___________________________

    Former Programs: ___________________________________________________________________________

    __________________________________________________________________________________________

    Did you complete your most recent program?               Yes         No

    If No, explain. _______________________________________________________________________________

    __________________________________________________________________________________________


Final Intake:
How did you hear about us? ______________________________________________________________________

    __________________________________________________________________________________________

Intake Counselor’s Name: _____________________________________________________


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                    SAMPLE WOMEN’S RESIDENCY INTAKE FORM – BENEVOLENCE SUPPORT SERVICES, LLC




Who would you rely on to be a support system while you seek recovery?

                 Name                               Relationship                           Phone




If you are accepted into our program, is there anything hindering you from coming in immediately? Yes/No?

   If Yes, explain. ______________________________________________________________________________

   __________________________________________________________________________________________

Can you or a family member pay your program fee of $75.00 a week? Yes/No?

NOTES:
  __________________________________________________________________________________________

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   __________________________________________________________________________________________

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   __________________________________________________________________________________________

   __________________________________________________________________________________________

   __________________________________________________________________________________________

   __________________________________________________________________________________________

   __________________________________________________________________________________________

   __________________________________________________________________________________________

*This is not a medical facility.
*We are not equipped for those suffering with mental disorders.



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                        SAMPLE WOMEN’S RESIDENCY INTAKE FORM – BENEVOLENCE SUPPORT SERVICES, LLC




Agreements:
The following agreements are acknowledged with the client’s initials and full signature.

    I agree not to hold YOUR ORGANIZATION’S NAME GOES HERE, its staff, volunteers, or any
    person connected to them, responsible for any accidents or injuries while I am in their care.            Initials _________

    I agree not to hold YOUR ORGANIZATION’S NAME GOES HERE responsible for any personal
    property that is lost, stolen, or damaged while I am in their care.                                      Initials_________

    I agree to allow YOUR ORGANIZATION’S NAME GOES HERE staff or volunteers to transport
    me in their personal vehicles. In the event of an accident I will not hold the aforementioned
    responsible.
                                                                                                             Initials_________

    I agree to return all linens, laundry box, lock and key and all other property that was loaned to
    me during my stay. If these items are lost or removed from the premises, I agree to pay for them
    or replace them.
                                                                                                             Initials_________

    I authorize the staff of YOUR ORGANIZATION’S NAME GOES HERE to release information
    concerning me to agencies that may be able to help me in the event of an emergency.                      Initials_________

    I have read the rules or had them explained to me. I understand that I must comply with all rules
    and procedures and am willing to do so. I understand that if I give false information or if I do not     Initials_________
    comply with the rules I will be asked to leave the premises immediately.


Signature____________________________
                      (Clients full signature)



Release Authorization:
I ___________________________________________ hereby authorize any representative of YOUR FULL ORGANIZATION
  (For Client: Print First, Middle Initial and Last Name Here)
NAME GOES HERE to release, as needed, all confidential information pertaining to my: physical condition(s), heath history, mode(s)
of living, avocation(s), age, occupation(s), social security claim(s) and other personal and psychological information. This
authorization includes information about drugs, alcoholism and mental Illness.

The entities to whom this privileged and personal information may be given include any physician, psychologist, medical practitioner,
hospital, clinic, other medical or medical related facility, any attorney, the legal Aid Society, Veterans Administration or other
government facility, the Medical Information Bureau reporting agencies, insurance or reinsuring companies or any employers having
information about me or any member of my family.

I know that I may request to receive a copy of this authorization. I agree that a photocopy of this release authorization shall be as
valid as the original.

Signature__________________________________
                      (Clients full signature)




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