Residential Treatment Program Application

Restore House

PO Box 1191, Bemidji, MN 56619

218-444-9420 (phone) 218-444-9212 (fax)

Mary Greer, Program/Treatment Director

218-760-4209 (phone)

Date

Personal Information:

Full Name:

(First) (Middle) (Last)

Address:

(Street, PO Box) (City) (State) (Zip Code)

Date of Birth: Social Security Number ______-______-______

Marital Status: ____Single____ Married____ Divorced____ Separated ____Engaged ____Widowed

Phone # Gender:___ Male ___ Female Are you a veteran? Yes No

Present Housing Situation:

____Live with Spouse ____Live with Friends ____Homeless

____Live with Parents ____Incarcerated ____Live Alone

____Live with Relative ____Other ______

Emergency Contact Person (relationship to you):

(Name)

(Street Address) (City) (State) (Zip Code) (Phone Number)

Second Emergency Contact Person (relationship to you):

(Name)

(Street Address) (City) (State) (Zip Code) (Phone Number)

Rule 25 Assessor: (Name) (Phone Number)

Date of last Rule 25/Chemical Dependency Assessment:

Corrections Agent (if applicable):

(Name) (Phone)

Attorney/Public Defender Information (if applicable):

(Name) (Phone)

Next Court Date (if applicable): Where:

Family Information:

Mother’s Information: Father’s Information:

Name: Name:

Street: Street:

City: City:

State: Zip Code: State: Zip Code:

Phone: ( ) Phone: )

Spouse’s Information: Circle one: Custodial parent

Name: Non-custodial parent

Street: Circle one: Supervised visitation

City: Non-supervised visitation

State: Zip Code:

Phone: ( )

Children’s Information:

Name: Sex: M F Age: DOB: / /

Educational Background:

Highest level of school completed:

List all schools, certificates and diplomas:

Religious Affiliation:

Name of church:

Address of church:

(Street) (City) (State)

Name of pastor: Telephone Number:

Write a brief biography of your life, including your spiritual experiences:

Have you ever been classified as a sex offender under Minnesota Law? Yes No

Or any other state? Yes No

Explain:

Applicants Signature:

(Signature) (Date)

Emotional Pain and Behavior Self-evaluation:

Please rate your emotional pain from 1 to 10 with 10 being the greatest.

Restore House: Residential Treatment Program Application

_____Anger/resentment

_____Abandonment

_____Attempted suicide

_____Bitterness

_____Rejection

_____Betrayal

_____Victim

_____Guilt

_____Shame

_____Criticism

_____Depression

_____Verbal abuse

_____Physical abuse

_____Sexual abuse

_____Self-condemnation

_____Self hate

_____Fearful

_____Any thoughts of suicide

Restore House: Residential Treatment Program Application

Check any behaviors listed below that you have in reaction to your emotional pain.

Restore House: Residential Treatment Program Application

_____Substance abuse

_____Violence

_____Sexual

_____Stealing

_____Revengeful

_____Dishonest

_____Overeating

_____Manipulative

_____Dependency

_____Withdrawn

_____Aggressive

_____Compulsive

_____Anorexia/Bulimia

_____Verbal abuse

_____Running away

_____Irresponsible

_____Judgmental

_____Lying

_____Hostility

_____Cutting/Burning

_____Defensive

_____Dramatic

_____Perfectionist

_____Extreme independence

Restore House: Residential Treatment Program Application

Financial Situation:

Are you working? _____Yes _____No If yes, where? Hours:

Supervisor: Phone number:

Monthly Income from Job: How long at this employment?

Other Income:

Source / Yes / No / Monthly Income
Social Security / $
Disability / $
Retirement Income (Pension) / $
Un-earned Income / $

Assistance Received:

Source / Yes / No / County
Food Stamps
General Assistance
Medical Assistance
Have you applied for assistance

Restore House: Residential Treatment Program Application

Please indicate the total current balance or present value for each of the following:

Restore House: Residential Treatment Program Application

$ Cash

$ 401 {K) Plan

$ Stocks

$ Savings Account

$ 403 (B) Plan

$ Bonds

$ Checking Account

$ IRA Accounts

$ Mutual Funds

$ Savings Bonds

$ Retirement Accounts

$ Trust Funds

$ Personal Property

$ Other Pension Plans

$ Tools of Trade

Restore House: Residential Treatment Program Application

Debts:

Source / Yes / No / Current Balance
Do you have any unpaid student loans? / $
Do you have any unpaid personal loans? / $
Do you have any unpaid vehicle loans? / $
Do you have any home mortgage loans? / $
Do you have any other property loans? / $
Have you co-signed for any unpaid loans? / $
Do you have any unpaid medical bills? / $
Do you have any credit card debts? / $
Do you have any unpaid fines/court costs? / $
Do you have any unpaid restitution? / $
Are you required to pay child support? / $
Do you owe any back child support? / $
Do you have any other unpaid debts? / $

Assets:

Source / Yes / No / Total Estimated Value
Do you own a home? / $
Do you own any real estate property? / $
Do you own any burial accounts? / $
Do you own any time share property? / $
Do you own any cash value life insurance? / $
Have you sold or transferred any property within the past 36 months? / $

Do you own any vehicles? Yes No How Many?

Vehicle #1 Make: Model: Value: $

Vehicle #2 Make: Model: Value: $

Legal Situation:

Current Legal Status: YES/NO If yes, list state/county

Are you currently on probation?

Are you currently on parole?

Do you currently have any court cases pending?

Do you currently have any outstanding warrants?

Are you currently under investigation for anything?

Are you currently involved in any type of lawsuit?

Are you currently ordered to do community service?

Are you currently required to pay child support?

Are you currently behind in child support payments?

Are you currently required to pay any restitution?

Do you currently have any unpaid fines?

Pending court dates: If yes, when?

Probation Officer? If yes, name of officer

What County Phone number

Past Legal Status: YES/NO If yes, list state/county/dates

Have you ever been arrested?

Have you ever been in a juvenile detention center?

Have you ever been sentenced to jail?

Have you ever been in prison?

Have you ever been on probation?

Criminal Activity: (Check all that you have been involved with and dates)

Restore House: Residential Treatment Program Application

___Aiding & Abetting

___Probation/Parole Violation

___Rape

___Restraining Order

___Sex with a Minor

___Shoplifting

___Stalking

___Terrorist Threats

___Truancy

___Underage Drinking

___Vandalism

___Vehicular Homicide

___Violation of Order of Protection

___Violation of Restraining Order

___Driving Without a License

___Drug manufacturing

___DUI

___DWI

___Escape from Custody

___Felony Conviction

___Fraud

___Harassment

___Kidnapping

___Larceny

___Manslaughter

___Murder

___Order of Protection

___Sale of Controlled Substance

___Driving Without A License

___Armed Robbery

___Assault

___Attempted Assault

___Attempted Robbery

___Attempted Murder

___Battery

___Burglary

___Child Abuse/Neglect

___Child Molestation

___Child Pornography

___Concealed Weapon

___Disorderly Conduct

___Drug Possession

___Prostitution

___Robbery

___Theft

___ Solicitation of Prostitution

___Incest

___Use of Firearm in a Crime

___No Drink Violation

___No Contact Order

___Violation of No Contact Order

___Criminal Sexual Conduct

___Child Endangerment

___Arson

___Attempted Rape

___Attempted Theft

___Car Jacking

___Possession of Stolen Property

___Leaving Scene of Accident

___Embezzlement

___Fleeing or Eluding Police

___Domestic Violence

___Other

Restore House: Residential Treatment Program Application

Applicant’s Signature:

(Signature) (Date)

Medical Information:

Physical Health Information:

Name of Doctor: Name of Clinic:

City: State: Phone:

Dates of Treatment: ____/____/_____ to ____/____/_____ Date of Last Physical: ____/____/_____

Reason for Treatment:

Dental Health Information:

Name of Dentist: Name of Clinic:

City: State: Phone:

Dates of Treatment: ____/____/_____ to ____/____/_____ Date of Last Check-up:____/____/_____

Reason for Treatment:

Mental Health Information:

Name of Psychiatrist:

Name of Clinic:

City: State: Phone:

Dates of Treatment: ____/____/_____ to ____/____/_____

Reason for Treatment:

Insurance Provider: [If you have MA, please list that and give your MA number]

Name of Insurance Company:

Name of Insurance Agent: ID Number/Policy Number:

Address:

(Street) (City) (State)

Phone Number: Fax:

Medical Needs:

Present medical concerns:

Any physical, mental or emotional health issues?

Are you currently taking any medications? _____Yes _____No If yes, list medications:

Medical History: (Indicate all that apply to your current and past conditions Write “C” if current and “P” if in the past)

Restore House: Residential Treatment Program Application

____ADD

____ADHD

____Alcohol Abuse

____Anorexia

____Asthma

____Back Problems

____Bipolar

____Bulimia

____Depression

____Diabetes

____Drug Abuse

____Eating Disorder

____Flashbacks

____Hallucinations

____Head Trauma

____Hearing Voices

____Heart Condition

____Hepatitis (type)

____High Blood Pressure

____HIV Virus

____Homicidal Tendencies

____Homicidal Thoughts

____Insomnia

____Mental Illness

____Multiple Personalities

____Nervous Condition

____Paranoia

____Physical Abuse

____Rape

____Respiratory Problems

____Schizophrenia

____Seizures

____Sexual Abuse

____Suicide Attempts

____Suicide Thoughts

____Tuberculosis

____Venereal Disease (STD)

____Other: ______

Restore House: Residential Treatment Program Application

Chemical Dependency:

Type of chemical/drug(s) of choice:

Date of last use: How often did you use:

Method of Use: ____Inject ____Snort ____Smoke ____Oral ____Other

Previous or current treatment program(s): _____Yes _____No

Number of programs in which you have participated: ______

Name(s) of programs:

Contact person at treatment program:

Longest period of sobriety: Do you have a current desire to use? ___Yes ___No

What led to your relapse:

Relapse pattern:

Do you have a relapse prevention program? ___Yes ___No If yes, which is it?

Substance Abuse: (Check all that you have used)

Restore House: Residential Treatment Program Application

____Alcohol

____Crack

____Huffing/Sniffing

____Mushrooms

____Amphetamines (uppers)

____Ecstasy

____LSD

____PCP

____Barbiturates (downers)

____GHB/MDMA

____Marijuana

____Over the Counter Drugs

____Cocaine

____Heroin

____Meth

____Prescription Drugs

____Other:______

Restore House: Residential Treatment Program Application

Do you use tobacco? ____YES ____NO

If yes, check all that apply: ____Cigarettes/Cigars ____Chew/Snuff

Special Needs:

Need / Yes / No / Type
Do you have any type of disability?
Do you require a special diet?
Do you have any medical restrictions?
Do you have any allergies?
Do you have any chronic conditions?
Do you have any other type of special needs?

Why are you interested in being a part of a Residential Treatment Program?

Who has encouraged you to become a part of Restore House?

In addition to completing this application, you may need to have a health physical, a urinalysis and a criminal background check (at your expense). When the required documents have been completed and returned to the Restore House program director and the committee has reviewed your application, you will be contacted regarding your acceptance/non-acceptance into the Residential Treatment Program. Thank you for your interest in our program and a positive lifestyle choice.

I authorize Restore House staff to contact any individuals named in this application. Also, I authorize Restore House staff to exchange information with board and committee members regarding application and acceptance.

Signature Date

Dismissal:

I understand that any violation of Restore House program rules could result in my immediate discharge and eviction from the program/home. No financial refund will be given.

Signature Date

Submitted to the committee: ______(Date)

Committee decision:

______

RESTORE HOUSE INC Residential Treatment Program Visitation List

(Name)______(Date)______

Individuals whom I choose to have approved by the Licensed Chemical Dependency Counselor [LADC]. I have kept in mind when choosing individuals those whom will positively influence me. Examples: family, sponsor, pastor, etc. Only those approved by the LADC will be allowed to visit and/or call.

Name / Phone / Relationship / LADC
Approved / Date Approved / Client Initials

By signing below, I hereby authorize Restore House to disclose my presence in the Restore House Program to the above named individuals, for the purpose of telephone calls, mail and visits while I am in residence at Restore House. This authorization will remain in effect for one year from the date it is signed, unless it is revoked by me prior to that date. This authorization, except for action already taken, can be revoked at any time. I understand that information concerning my presence at Restore House cannot be released without my written consent unless otherwise provided for in legal statutes and judicial orders. My signature below indicates that I understand the conditions of this release and that I give my authorization voluntarily.

Client's signature Date

X ______

LADC/Program Director Date

I revoke this authorization for Release of Information on 20 for the above designated person or persons.

Restore House: Residential Treatment Program Application

Client's Signature

Witness Initials

Restore House: Residential Treatment Program Application

NOTE: To revoke permissions in regards to a specific individual on this list the client should write "REVOKED" over the individual's name, date and initial the change. Staff who witnesses the revocation should also initial the entry.

Restore House: Residential Treatment Program Application