Healing Point House
Initial Eligibility Assessment Application
Today's Date:
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Month
-
Day
Year
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Applicant name:
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First Name
Last Name
Date of birth:
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Month
-
Day
Year
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Current address:
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Street Address
Apt/Suite
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Is your mailing address different from your current address?
*
Yes
No
Mailing address:
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone number:
*
Please enter a valid phone number.
Email:
example@example.com
Marital status:
*
Please Select
Married
Single
Divorced
Widowed
Number of dependents:
*
How were you referred to Healing Point House?
*
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Substance Use
Date of last use:
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Month
-
Day
Year
Date
12-Step/SMART Recovery
I have participated in a 12-Step program:
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Yes
No
I currently have a sponsor:
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Yes
No
I am willing to find a sponsor:
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Yes
No
I am currently working the 12-Steps:
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Yes
No
I have worked other programs besides 12-Steps, like SMART Recovery or something else:
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Yes
No
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Treatment
I am currently in treatment for alcohol and/or substance abuse:
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Yes
No
I have attended treatment at some point for alcohol and/or substance abuse.
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Yes
No
Legal
Do you have any convictions for violent or sexual offenses?
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Yes
No
Medical
Are you currently taking any prescribed medications?
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Yes
No
Do you require any accommodations for accessibility at Healing Point House?
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Yes
No
Please explain required accommodations:
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Employment
Current income range:
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Please Select
$0 - $10,800
$10,801 - $24,000
$24,001 - $50,000
$50,001+
Are you currently employed?
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Yes
No
Do you believe you can find employment within the next month?
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Yes
Np
Do you have financial commitments that may cause you difficulties in paying the program fee? (Program fee is $125/week)
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Yes
No
Please explain:
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Please list all your sources of income:
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I certify that the information I have provided in this application is correct to the best of my knowledge. I confirm that any misrepresentation of facts I have provided would be grounds for removal from the Healing Point House Sober Living Program. I acknowledge that I understand I will not be considered for residency at the Healing Point Sober Living House if I have any history of violent or sexual offenses. I also understand that my spouse/partner/children/other dependents may not reside with me.
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