Intake Application Questions
Have you ever applied with us before?
Your full name
Your phone number
Your email address
Your previous address: city, state, postal code
Your social security number
Your date of birth
Your gender
If female, pregnant?
Is smoker?
Which do you smoke?
Marital status
Spouse's full name (if applicable)
What is your primary language?
Full name of the person we can contact in case of emergency
Your emergency contact's phone number
How are you related to your emergency contact
Emergency contact address
Who referred you to this house?
If other referrer, please explain
Legal Information / History
Do you have any pending cases?
If yes, explain
Previous involvement with the criminal justice system?
If yes, explain
Are you currently on probation or parole?
Criminal justice contact / PO full name
Criminal justice contact / PO phone number
Number of arrests in the last 30 days
Have you been arrested for, or have you ever been the subject of a case that involved arson?
If yes, what was the year of the arrest?
Have you been arrested for, or have you ever been the subject of a case that involved sexual assault
If yes, what was the year of the arrest?
Have you been arrested for, or have you ever been the subject of a case that involved sexual offense against a minor
If yes, what was the year of the arrest?
Health Status
Do you currently experience, or have a history of psychiatric conditions?
If applicable, describe / list:
Do you currently experience, or have a history of addiction disorders?
If applicable, describe / list:
Do you currently experience, or have a history of medical conditions?
If applicable, describe / list:
Do you currently experience, or have a history of trauma / abuse?
If applicable, describe / list:
Are you currently taking any prescribed medications?
If applicable, describe / list:
Do you have a service or assistance animal?
Explain any other current health problems:
Allergies
Current provider agency, if applicable:
Admission date
Current doctor / clinician / worker
Current doctor / clinician / worker phone number
Drug / Alcohol History
Drug(s) of choice
Method of use
Number of uses last 30 days
Age at first use
Do you attend AA / NA
Number of times attended in the last 30 days
Date of last use
What is your longest period of sobriety or stability?
Employment & Education
Employment status
Highest grade completed
Entitlements And Benefits
Principal source of income
Benefits
If applicable, who is your insurance provider?
If applicable, Medicaid status
If applicable, SSD/SSI status?
Other State/Provider Agency Involvement
Are you currently working with an agency or case manager or sponsor?
Worker's full name
Worker's phone number
Worker's email address
Worker's organization
Family And Supports
Do you feel you have social supports (family, friends, etc)?
How would you describe your current relationship with your family members?
Housing Status
Living situation immediately prior to this residence
If other, specify
Reason for leaving
Have you been homeless within the last six months?
Are you at risk of homelessness?
How many of the last 30 days have you been in a controlled environment?
If approved for a Haven Hall Residence, which of the following cities do you prefer?
Victoria, TX
San Antonio TX
When do you need to check-in (or what is your discharge date)?
Do you currently own or have a vehicle that you intend to keep on site?
In The Licensee's Own Words
Are you interested in maintaining a sober lifestyle?
What do you think is your biggest or most challenging issue?
What are the relapse triggers you can recognize?
What are your strengths?
What specific assistance or support would best help you to reach your goals?
Is there anything else you can tell us about yourself that would assist us in helping you meet your goals?