Charis House ApplicationYour next steps to recovery start here. Name * First Name Last Name Date of Birth * MM DD YYYY Race What sex were you born at birth? * Phone * (###) ### #### Current Address * Highest level of education: * GED/High School Diploma Trade School/College Degree Bachelor's/Master's Degree None of the above Describe your work experience: Do you have a monthly income? * Yes No Do you receive SSI or any other supplemental income? * Yes No Criminal background: * Outstanding Warrant(s) Probation Pending Court Dates Currently Incarcerated Other criminal background not listed None of the above If currently incarcerated: what facility, what is your expected release date, and your next court date? Do you have children? * Yes No If you have children, please list the names and ages of each of them: Do you receive monthly support for any dependent children? * Yes No Are you currently working a case plan with DCF or Families First to be reunited with your children? * Yes No Is your mother alive? * Yes No If your mother is alive, please provide her phone number and the last time you spoke with her: Is your father alive? * Yes No If your father is alive, please provide his phone number and last time you spoke with him: Are you married? * Yes No If you are married, please list spouse's name: Do you have a boyfriend/girlfriend? * Yes No Do you have any on-going relationships that would interfere with your focus on recovery? * Who will you rely on to be a support system while you seek recovery? * Do you have any physical/medical conditions or disabilities? If so, please list: Do you have any medical problems that have been on-going and require monitoring by a physician? Do you have medical insurance? * Yes No Please list any medical conditions: If you do have any medical conditions, are you taking your prescribed medication? Yes No If applicable, list the doctor who prescribes these medications: If applicable, list the medications you take: Have you ever been hospitalized for a mental health issue? * Yes No Have you ever had a mental health evaluation? * Yes No Check all you have been diagnosed with in the past: * Depression Anxiety Bipolar Disorder Schizophrenia PTSD Personality Disorder ADD/ADHD Drug Related None of the above If applicable, did your mental health symptoms begin before, during, or after drug use? Do you have a family history of mental illness? * Yes No Are you stable on your medications? * Yes No Not on medications Have you ever had an abortion? * Yes No Is there a possibility you are pregnant? * Yes No Do you need glasses? * Yes No Have you ever binged/purged with food in the past, or been diagnosed with an eating disorder? * Yes No Have you ever engaged in cutting or self-mutilation? * Yes No Have you ever been so angry that you harmed yourself? * Yes No Have you ever been so angry that you tried to harm someone else? * Yes No Have you ever tried to commit suicide? If yes, please explain. * Have you experienced abuse? * Verbal Abuse Physical Abuse Mental Abuse Sexual Abuse Other None Do you have any dental needs? * Yes No Do you smoke cigarettes/vape? * Yes No If you do smoke cigarettes/vape, are you willing to quit? Yes No List of drugs/alcohol you have abused: What is your substance of choice? At what age did you start using drugs/alcohol? When was the last time you used drugs/alcohol? Have you participated in a treatment program in the past? * Yes No If applicable, name(s) of program(s) your participated in and the year you entered/left those programs: If applicable, did you complete these programs? Yes No What is the longest time you have been clean/sober? * Are you willing to live in a multi-racial and multi-cultural controlled environment? * Yes No Are you willing and able to commit to a full day of classes and work therapy? * Yes No Are you willing to adhere to a dress code? * Yes No Do you have an ID or birth certificate? * What is your religious background? * What is your goal? * Signature (Type Full Legal Name) * Today's Date * MM DD YYYY Thank you!
