Honest Beginning Online Admission FormAll sections are required to be filled out.Note: Completion of application form does not guarantee admission to Honest Beginnings Inc. Honest Beginnings Inc., 689 Federal St., Belchertown MA, 01007 (this is not mailing address) APPLICATION FORM Note: Completion of application form does not guarantee admission to Honest Beginnings Inc. PART 1 | Background Information Date MM DD YYYY Name First Name Last Name Address: 689 Federal St., Belchertown MA, 01007 Home Phone (###) ### #### Mobile Phone (###) ### #### Email Date of Birth MM DD YYYY Are you a Veteran? Yes No If yes, select military branch None Army Navy Air Force Marine Corps Coast Guard Space Force Are you on Probation or Parole? Probation Parole None If yes, Location: Parole Officer Name First Name Last Name Parole Officer Phone (###) ### #### Do you currently have any open cases or warrants? If yes, please explain. I'm taking the following medication(s): PART 2 | Legal Information Are you legally Mandated to us? Yes No Legal Charge? On Probation? Yes No On Parole? Yes No Outstanding Warrants? Yes No Supervision Officer Name First Name Last Name Supervision Officer Address Address 1 Address 2 City State/Province Zip/Postal Code Country Supervision Officer Phone (###) ### #### Supervision Officer Fax (###) ### #### Has release of information been signed? Yes No PART 3 | Addiction History Current Recovery Date MM DD YYYY Alcohol Yes No Type of Alcohol Amphetimines Yes No Type of Amphetimines Benzoids Yes No Type of Benzoids Cocaine Yes No Type of Cocaine Hallucinogen Yes No Type of Hallucinogen Marijuana Yes No Type of Marijuana Opiates Yes No Type of Opiates Other Yes No Describe Other Have you ever relapsed? Yes No Number of Times Drug(s) of Choice? Date of Last Use (if you know) MM DD YYYY How long have you been drug and alcohol free? Less than a month 1 to 3 months 4 to 6 months 7 months to a year More than one year If less than a month, how many days? Referred By Entry Date MM DD YYYY Have you lived at Honest Beginnings before? Yes No If yes, when? 1. How old were you when you first used drugs/drank? 2. Have you ever been in a Drug/Alcohol Treatment Center? When? 3. Have you ever been in a halfway house? When? 4. What is your highest level of education? High School Graduate GED College/University Other If Other, please explain 5. Have you ever been in prison? How many times? 6. Where did you live before moving here? (City/State) 8. Are you employed? If yes, what kind of work do you do? 9. What are your means of transportation? 10. What is your source of income? 11. Marital Status Single Married Seperated Divorced Widowed 12. Have you ever received any DUI's or DWI's? If yes, how many? 13. Do you have any children? If yes, how many? 13. What kind of problems has drinking and/or drug use caused you? 14. Are you prejudiced towards any group or race? If yes, explain 14. What kind of medical problems (physical or emotional) do we need to know about you? PART 4 | Emergency Information Emergency Contact 1 First Name Last Name Relationship Address Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact 1 / Phone 1 (###) ### #### Emergency Contact 1 / Phone 2 (###) ### #### Emergency Contact 2 First Name Last Name Relationship Address Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact 2 / Phone 1 (###) ### #### Emergency Contact 2 / Phone 2 (###) ### #### HEAD MANAGER CONDITIONS (to be written by the Head Manager) Conditions Prior To Entry: PART 5 | Demographic Information Gender Male Female Other Prefer not to say Race Caucasion African American Native American Asian-Pacific Islander Hispanic Other Professional License (MD, DVM, etc.) Profession / Employment Household Income (Check One) Less than $10,000 $10,000 – 25,000 $25,000 – 50,000 $50,000 – 75,000 Over $75,000 Military Service Yes No If Yes, Miltary Branch Type of Discharge Previous Diagnosis (Check all that Apply) Substance Abuse Eating Disorder Mood / Personality Disorder Specify Mood / Personality Disorder Type Education (Check Highest Grade Completed) Less than HS HS / GED Some College 2 Year Degree 4 Year Degree Masters or PhD Religious Preference Protestant / Christian Catholic Jewish Islamic Other PART 6 | Final Questions Please answer the following questions below. 1. Who suggested that you come here (chose one option that best applies)? Family / Friend Employer / Coworker Treatment or human services professional Representative of the courts/judicial system Other None 2. How long have you been drug and alcohol free? Less than a month One to three months Four to six months Seven months to a year More than one year If less than a month, How many days? 3. In the past 30 days, where have you been living most of the time (chose one option that best applies)? My own home / apartment Someone else’s home / apartment In a medical, treatment, or other residential recovery setting In jail, prison, or another correctional setting In a shelter or another temporary housing facility Outdoors or on the streets Other 4. Are you currently enrolled in school or a job training program? Not enrolled Enrolled full-time Enrolled part-time Other 5. Are you currently employed (chose one option that best applies)? Employed full-time (35+ hours per week) Employed part-time Unemployed and looking for work Unemployed and not looking for work (e.g., retired, disabled, enrolled in school, etc) Other If Other, Explain: 6. In the past 30 days, did you attend any self-help or recovery support groups? Yes No If Yes, what type? How many? 7. How would you rate your quality of life? Very poor Poor Good Very good Neither poor nor good 8. What would you like to accomplish during your stay here? 9. What are your top 3 goals and why did you pick these? 10. What potential challenges do you see in improving your recovery? 11. What else would be helpful for us to know about you to best serve you? PART 7 | Authorization Signature BY MY SIGNATURE BELOW, I AGREE TO ANY AND ALL TERMS AND CONDITIONS SETFORTH ABOVE BY THE HOUSE MANAGER. IN ADDITION, I ATTEST THAT ALL INFORMATION I HAVE PROVIDED IS ACCURATE TO THE BEST OF MY KNOWLEDGE Member Name First Name Last Name Member Date MM DD YYYY Witness Name First Name Last Name Witness Date MM DD YYYY House / Office Manager First Name Last Name House / Office Manager Date MM DD YYYY Thank you!
