Heart of Hannah Outreach Center

HEART OF HANNAH OUTREACH CENTER

(H.O.H.O.C.)

RENEWAL/RECOVERY PROGRAM

11400 OLD WHITE HORSE RD.

TRAVELERS REST, SC 29690

864-834-5600

E-mail:

RESIDENT APPLICATION:

NAME: ______ADDRESS: ______

CITY: ______STATE: ______ZIP: ______

HAVEYOU EVER BEEN A RESIDENT OF H.O.H.O.C. _____ YES _____ NO

TELEPHONE:

HOME: ______CELL: ______WORK: ______

AGE:_____BIRTHDATE: ______SEX:____ RACE: ______RELIGION:______

MARITIAL STATUS: ______MAIDEN NAME: ______

(If married give spouse name)

OCCUPATION: ______SSN:______

ABLE BODIED ____ or DISABLED ______AMOUNT OF DISABILITY ______

HAVE YOU OR ARE HOMELESS? _____yes _____no

IF SO, HOW MANY TIMES? _____

WHAT LOCATIONS:

1.  ______

2.  ______

3.  ______

CHILDREN INFORMATION:

NAME AGE

______

______

______

______

CUSTODY OF CHILDREN:

______

IS CHILD/REN ENROLLED IN SCHOOL? _____ yes _____ no

ARE THERE AGENGIES INVOLVED: ___ DSS ___ JUVENILE COURT ___OTHER

NOTIFY IN CASE OF EMERGENCY;

NAME:______ADDRESS: ______

CITY: ______STATE: ______ZIP: ______

TELEPHONE: HOME______CELL: ______

RELATIONSHIP:______

REHAB OR RECOVERY PROGRAM THAT YOU COMPLETED

(NAME AND CITY):

______

NAME OF CURRENT REHAB OR RECOVERY PROGRAM:

______

NAME OF COUNSELOR: ______TELEPHONE: ______

RELEASE DATE: ______SOBRIETY AND/OR CLEAN DATE: ______

REASON FOR APPLYING TO H.O.H.O.C.: ______

SUBSTANCE ABUSE ADMISSION ASSESSMENT:

SYMPTOMS:

____NONE ___ ATTEMPTS TO CUT DOWN

____INCREASED TOLERANCE ___ WITH-DRAWAL

____FAMILY/RELATION PROBLEMS ____JOB PROBLEMS

____GUILTY ABOUT ACTIONS WHILE USING

PLEASE FILL IN THE FOLLOWING, USE CHART BELOW TO CHOOSE FROM.

EXAMPLE:

ALCOHOL 01 01 01 13 WEAK, SICK

SUBSTANCE CODE ROUTE FREQUENCY AGE WITHDRAWAL

WHEN USING SYMTOMS/SPECIFY

______

SUSTANCE CODES:

00 None 06 Opiates/Synthetics 12 Benzodiazepine

01 Alcohol 07 PCP 13 Tranquilizers

02 Cocaine/Crack 08 Hallucinogens 14 Barbiturates

03 Marijuana/Hashish 09 Meth Amphetamine 15 Sedatives

04 Heroin 10 Amphetamines 16 Inhalants

05 Methadone 11 Stimulants 17 Over-the-Counter

ROUTE CODES:

1 ORAL 2 SMOKING 3 INHALING 4 INJECTION 5 OTHER

FRENQUENCY CODES:

00 DRUG NOT USED DURING THE PAST MONTH

01 DRUG USED 1-3 TIMES IN THE PAST MONTH

02 DRUGS USED 1-2 TIMES PER WEEK

03 DRUGS USED 3-6 TIMES PER WEEK

04 DRUGS USED DAILY

MEDICAL HISTORY:

PLEASE CIRCLE:

DIEBETES HIGH BLOOD PRESSURE HEART DISEASE

STROKE SEIZURES LIVER OR KIDNEY DISEASE

CANCER THYROID OR HORMONAL INFECTION DISEASE

PREGNANT SURGERIES (TB, AIDS, HIV, ETC)

DO YOU TAKE ANY MEDICATION? ____ LIST NAME AND DOSAGE.

1.  ______

2.  ______

3.  ______

4.  ______

5.  ______

6.  ______

WE CANNOT ACCEPT RESIDENTS TAKING THE FOLLOWING MEDICATIONS:

ALPROZOLAM (XANANX)

CHLORDIAZPOXIDE (LIBRIUM)

CLONAZEPAM (KLONOPIN)

CLORAZEPATE (TRANXENE)

DIAZEPAM (VALIUM)

FLURAZEPAM (DALMANE)

LORAZEPAM (ATIVAN)

OXAZEPAM (SERAX)

PRAZEPAM (CENTRAX)

TERNAZEPAM (RESTORIL)

TRIAZOLAM (HALCIO)

ANY MEDS HAVE TO BE APPROVED BY STAFF.

THESE MEDICATIONS ARE HIGHLY ADDICTIVE AND THE POTENTIAL FOR ABUSE EXISTS. THE RESIDENTS SELF-ADMINISTER THEIR OWN MEDICATION WITH STAFF SUPERVISON. WE FEEL THESE MEDICATIONS ACTUALLY MAINTAIN A PERSON IN THEIR ADDICTION.

TRAUMA, INCLUDING HEAD, PHYICAL/SEXUAL ABUSE: YES OR NO

(IF YES, PLEASE EXPLAIN)

______

ALLERGIES TO ENVIROMENT, FOOD, OR MEDICATION: YES OR NO

(IF YES, PLEASE EXPLAIN)

______

LEGAL:

HAVE YOU EVER BEEN CONVICTED OF A CRIME? _____YES ____ NO

IF SO, PLEASE GIVE NATURE OF CHARGE AND DATE OF CONVICTIONS:

______

DID ANY CONVICTIONS LEAD TO INCARCERATION?_____YES ____ NO

IF SO, PLEASE LIST INSTITUTIONS AND YEAR OF CONFINEMENT:

______

HAVE YOU EVER BEEN CONVITED OF A SEXUAL OFFENSE? ___ YES ____NO

IF SO, PLEASE LIST WHERE:

______

PAROLE OR PROBATION OFFICER:

NAME:

______

ADDRESS:

______

______

______

TELEPHONE:

______

SOCIAL WORKER:

NAME:

______

ADDRESS:

______

______

______

TELEPHONE:

______

MISCELLANEOUS:

WILL YOU BE ABLE TO PAY OUR WEEKLY SERVICE FEE IN THE AMOUNT OF $125.00. (All monies paid are non-refundable) _____ YES ____ NO

IF YOU ANSWERED NO, THEN WHO WILL BE PAYING?

NAME: ______PHONE: ______

DO YOU SMOKE? _____ YES ____ NO

IF YOUR ANSWER IS YES, THEN YOU WILL BE REPOSIBLE FORYOUR OWN CIGARETTES. (SMOKING IS ALLOWED OUTSIDE ONLY FROM 8:00 AM TIL 10:00 PM.) NO BORROWING OR ASKING FOR CIGARETTES.

WILL YOU HAVE EXTRA MONEY TO PURCHASE YOUR CIGARETTES? _____YES _____ NO

DO YOU HAVE A VALID DRIVERS LICENSE? _____ YES _____ NO

IF YES, WHAT IS THE LICENSE NUMBER? ______

WHAT STATE: ______

DO YOU HAVE A PICTURE ID? ____ YES ___ NO

IF YES, WHAT IS YOUR ID NUMBER? ______

WHAT STATE: ______

DO YOU HAVE FUTURE APPOINTMENTS (i.e. DOCTOR’S, DENTIST, SOCIAL SERVICE, PAROLE/PROBATION, AND/OR COURT DATES? IF YES, EXPLAIN:

______

DO YOU HAVE TRANSPORTATION TO AND FROM THESE APPOINTMENTS?

____ YES ____ NO

OUT OF TOWN APPOINTMENTS WILL BE YOUR RESPONSIBILTY IN MOST CASES.

YOU WOULD HAVE TO HAVE A TB AND HIV TEST DONE WITHIN THE PAST YEAR AND PRESENT THE RESULTS AT THE DAY OF YOUR ARRIVAL.

SINCE WE RAISE MONIES TO BE ABLE TO TAKE CARE OF HEART OF HANNAH OUTREACH CENTER REPOSIBLITIES, WE ASK THAT IF YOU HAVE A FOOD STAMP CARD THAT YOU TURN THAT INTO THE OFFICE UPON ARRIVAL OR WE WILL TAKE YOU TO GET ONE WHEN YOU ARRIVE. IT TAKES $300.00AWEEK PER LADY AND YOU ONLY PAY $125.00 SO WE HAVE TO DO OTHER THINGS TO HELP OUT FOR THE COST.

SIGNED: ______DATE: ______

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