APPLICATION FOR ADMISSION FOR GATEWAY HOMES-Supported Living Program
Mail completed applications to: Molly Bowles, Gateway Homes,
PO Box 460, Chesterfield VA 23832
Date: ____ Date of Gateway Tour:
NAME: (Last) (First) (Middle)
ADDRESS: ______
CITY: ______STATE: ZIP: ______
PHONE NUMBER: SOCIAL SECURITY # ______
GENDER (circle one): Male Female
MARITAL STATUS (circle one):Single/Never MarriedDivorcedMarried
SeparatedWidowed
ETHNICITY (circle one):African-AmericanCaucasian (White)
AsianNative American
HispanicOther
AGE:______BIRTHDATE: ______
BIRTHPLACE: ______
Current Residency:County ______
City:______
State:______
HOW DID YOU HEAR ABOUT GATEWAY HOMES?______
______
Clinical Information
- Current Diagnosis:______
______
______
- Current Medications:______
______
- Do you believe that you have a mental illness now and need to take medications?
__Yes __No
- Psychiatric History including age at onset and hospitalizations:______
______
______
______
- Past outpatient treatment history:______
______
- Please check all the symptoms that you have previously experienced:
Auditory/visual hallucinations Yes No
Delusional thought processes Yes No
Depressed mood Yes No
Mania Yes No
Anxiety Yes No
Obsessions/Compulsions Yes No
Eating-disordered behaviors Yes No
- Have you ever attempted suicide?
Yes No
If so, when and by what means?______
- Have you ever engaged in self-harm behaviors (e.g., self-cutting, burning, head banging, etc.)
__Yes __No
Have you ever engaged in physical or verbal aggression towards others?
If so, please explain ______
- List any history of substance use including the type of substance, amount and date last used:______
______
- List any current medical conditions:______
- List any operations or surgeries that your have had including dates:
______
- Have you experienced:
a. Seizures Yes No
b. Fainting spells Yes No
c. Head injury Yes No
Daily Living
1a. What is your current living situation? (Please check one)
State hospital With family
Community/Private Hospital Homeless
Group Home Other
Independent in an apartment/house
b. How long have you been in your current living situation? (Please check one)
less than 1 month 6 months B one year
1-6 months more than one year
2. How many different places have you lived during the past year? ______
3a. Have you ever lived independently?
Yes No
b. If Yes, what was the longest time you lived independently?
less than 1 month 6 months B one year
1-6 months more than one year
- Please describe difficulties that you had while living independently or what has prevented you from living independently. ______
______
5. Please check all of the activities that you are able to complete independently and without assistance from others:
personal hygiene meal preparation
personal finance/budgeting housekeeping
medication administration
Educational/Vocational/Social
- What is the highest grade you completed? ______
- Did you attend special education classes? __ Yes __ No
If Yes, what type? ______
- Have you ever served in the Armed Forces? __ Yes __ No
If Yes, list branch and dates of services:______
______
- List employment held and dates: ______
______
______
______
- What are your hobbies, interests, special talents? ______
______
______
- Describe your strengths and perceived limitations:______
______
______
______
______
______
Legal
- Have you ever incurred legal charges? __Yes __ No
If Yes, please describe and give dates chargesincurred:______
______
______
______
2 . Have you ever physically assaulted someone?
Yes No
If Yes, please describe any physical altercations you have had, including the date, what started it, and the result:______
______
______
3. Have you ever engaged in destruction of property?
Yes No
If Yes, please describe the incident(s), including the date and the result:______
______
______
4. Have you ever been accused of, charged with, or convicted of a sexual offense?
Yes No
5. Are you subject to a lifetime sex offender registration requirement in any state? __ Yes __No
6. Do you have an advanced directive? __Yes __No
7. Are you an NGRI? ___ Yes____ No
Who is your hospital liaison? ______
8. Are you on Probation or Parole? ____Yes ____ No
If so, how long are you under supervision? ______
Who is your direct contact for Probation or Parole?
Name: ______Phone: ______
FUTURE GOALS
- Why do you want to come to GW: ______
______
- What do you hope for yourself for the future? ______
______
- Please use this space to let the clinical team know any other information about you that you would like to share:______
CONTACT INFORMATION
- DESIGNATED CONTACT NAME : ______
CONTACT ADDRESS: ______
CITY: ______STATE: ______ZIP: ______
CONTACT PHONE NUMBER: ______
- NEXT OF KIN - NAME: ______
CONTACT ADDRESS: ______
CITY: ______STATE: ______ZIP: ______
CONTACT PHONE NUMBER: ______
- CASE MANAGER - NAME: ______
CONTACT ADDRESS: ______
CITY: ______STATE: ______ZIP: ______
CONTACT PHONE NUMBER: ______
- PERSONAL PHYSICIAN – NAME: ______
CONTACT ADDRESS: ______
CITY: ______STATE: ______ZIP: ______
CONTACT PHONE NUMBER: ______
FINANCIAL INFORMATION
Medicaid Number:______Medicare Number:______
Your sources of income:Monthly amounts of income:
SSI, SSDI, SSA Who is payee for benefits ______
Auxiliary Grant Who is your Gaurdian or Conservator? ______
Employment
Allowance
Payments from insurance companies
Military / Veterans Benefits _
Food Stamps______
Any Other Income
VALUE YEARLY INTEREST
Checking Account
Savings Account
Certificate of Deposit
Money Market Accounts
Treasury Bills
Stocks, bonds
Retirement or pension
Annuities
Personal Property held as an investment
Other
Have you received any lump sum payments during this past year, such as inheritances, insurance settlements, etc.? YES NO
Have you disposed of any assets for less than fair market value in the last two years? YES NO
Are you the owner of any Life Insurance policies with a cash-in value? YES NO
Are you the beneficiary of a Trust Fund? YES NO If so, how much income do you receive from this trust yearly?
IN ORDER FOR THIS APPLICATION TO BE COMPLETE AND CONSIDERED FOR APPROVAL, ONE OF THE FOLLOWING THREE DOCUMENTS MUST BE INCLUDED:
1.a) Letter from the Social Security Administration determining the applicant’s disability OR statement from Social Security Administration stating current benefit(s);
b) Proof of Medicaid enrollment or proof that application has been made;
2.Documentation from public agency of service agreement; or
3.Statement from applicant and/or family stating that full cost will be paid out of pocket.
*While a resident of Gateway, I agree that Gateway will serve as my representative payee for my social security benefits.
I certify that the information provided for this application is complete and accurate.
Signature of Applicant: ______Date: ______
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Form: April 2014F