About US apply Resident Application Form Step 1 of 4 25% P.O. Box 30035 1059 Main St., Worcester, MA 01603-0035 FAX 508.793.9568 Phone 508.755.6403Name* First Last Alias:Referral InformationReferred by (agency, institution):*Contact Person/ Case Mgr.:*Phone*Date Admitted to your AgencyUse of ASAM to Determine 3.1 Level of Care* Yes No Have you or has patient been admitted here before?* Yes No If so, when:Demographic InformationGender* Male Transgender Other Height:Weight:Massachusetts Resident? Yes No Primary Language:Are you currently homeless?* Yes No Last Known Residence:Criteria met? Yes No Date of Birth* MM slash DD slash YYYY Social Security #*Status: Single Married/Partnered Divorced/Separated Widowed FamilyChildren Yes No If yes, children, how many? Ages?Do you have custody? Yes No Physical Legal If no, who has custody?Do you have visitation rights? Yes No Demographic Information ContinuedEducation:Last grade completedOccupation:Date last worked:Specific Needs: (i.e., dietary issues, hearing impairment, allergies, etc.)Do you have access to your ID?YesNoIf yes please bring with you Forms of Identification:Legal HistorySelect all that apply* Probation Parole Case Pending Outstanding Warrants Restraining Order None OtherAttorney Name:Attorney Phone:Probation/Parole Officer Name:Probation/Parole Officer Phone:Court:Court Phone:Criminal HistoryHave you ever been convicted of any of the following?* Arson Murder Rape Kidnapping Assault SexCrimes None Other Convictions:Outcome: Psychiatric HistoryHave you ever been diagnosed with a psychiatric illness? Yes No Psychiatric Diagnosis(s):Psychiatric Hospitalizations: Yes No When:Where:How many:Prescribed Medication: Yes No Prescriber:PhoneMedicationsMedication NameDoseLast takenMedication NameDoseLast takenMedication NameDoseLast takenMedication NameDoseLast takenHave you stopped taking any medication in last 6 months for any reason? Yes No Why?Are you or have you ever been physically abusive towards yourself? Yes No Are you or have you ever been abusive towards others? (physically/emotionally/sexually) Yes No Are you or have you ever been a victim of violence? I am a victim of violence I have been a victim of violence I have NOT been a victim of violence If yes to above please elaborate:History of Suicide Attempts Yes No If yes to above please provide dates and treatment outcome.Substance Use InformationLast Date Used: (any substance) MM slash DD slash YYYY Number of treatments: Detox Residential Outpatient Methadone Drunk Driver Other If other:What Substances Were Last Used:Do you attend recovery meetings? Yes No Longest Clean Time:How long ago?Drug(s) of Choice:Date of TreatmentWhereOutcomeDate of TreatmentWhereOutcomeDate of TreatmentWhereOutcomeDo you use tobacco? Yes No Are you interested in quitting tobacco? Yes No Any other addictions?Intravenous Drug Use? Yes No When: Substance Use Information (cont.)Alcohol - Age of First UseAlcohol - Last UseAlcohol - FrequencyAlcohol - Usual RouteCocaine - Age of First UseCocaine - Last UseCocaine - FrequencyCocaine - Usual RouteCrack - Age of First UseCrack - Last UseCrack - FrequencyCrack - Usual RouteMarijuana/Hashish - Age of First UseMarijuana/Hashish - Last UseMarijuana/Hashish - FrequencyMarijuana/Hashish - Usual RouteHeroin - Age of First UseHeroin - Last UseHeroin - FrequencyHeroin - Usual RouteNon Rx Methadone - Age of First UseNon Rx Methadone - Last UseNon Rx Methadone - FrequencyNon Rx Methadone - Usual RouteOther Opiates - Age of First UseOther Opiates - Last UseOther Opiates - FrequencyOther Opiates - Usual RoutePCP - Age of First UsePCP - Last UsePCP - FrequencyPCP - Usual RouteOther Hallucinogens - Age of First UseOther Hallucinogens - Last UseOther Hallucinogens - FrequencyOther Hallucinogens - Usual RouteMethamphetamine - Age of First UseMethamphetamine - Last UseMethamphetamine - FrequencyMethamphetamine - Usual RouteOther Amphetamines - Age of First UseOther Amphetamines - Last UseOther Amphetamines - FrequencyOther Amphetamines - Usual RouteOther Stimulants - Age of First UseOther Stimulants - Last UseOther Stimulants - FrequencyOther Stimulants - Usual RouteBenzodiazepines - Age of First UseBenzodiazepines - Last UseBenzodiazepines - FrequencyBenzodiazepines - Usual RouteOther Tranquilizers - Age of First UseOther Tranquilizers - Last UseOther Tranquilizers - FrequencyOther Tranquilizers - Usual RouteBarbiturates - Age of First UseBarbiturates - Last UseBarbiturates - FrequencyBarbiturates - Usual RouteOther Sedatives/Hypnotics - Age of First UseOther Sedatives/Hypnotics - Last UseOther Sedatives/Hypnotics - FrequencyOther Sedatives/Hypnotics - Usual RouteInhalants - Age of First UseInhalants - Last UseInhalants - FrequencyInhalants - Usual RouteOver-the-Counter - Age of First UseOver-the-Counter - Last UseOver-the-Counter - FrequencyOver-the-Counter - Usual RouteEcstasy - Age of First UseEcstasy - Last UseEcstasy - FrequencyEcstasy - Usual RouteNicotine - Age of First UseNicotine - Last UseNicotine - FrequencyNicotine - Usual RouteCaffeine - Age of First UseCaffeine - Last UseCaffeine - FrequencyCaffeine - Usual RouteOther - Age of First UseOther - Last UseOther - FrequencyOther - Usual RouteOther - Age of First UseOther - Last UseOther - FrequencyOther - Usual RouteIn Case of Emergency Notify(obtain release with signature)Name First Last PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Relationship:Military HistoryHave you served?* Yes No What type of discharge did you receive?Enlistment Date:Discharge Date:Were you involved in armed conflict? Yes No What branch of service were you in?Where: Medical HistoryPrimary Care Physician:Write "none" if applicable.PhoneDate of last physical exam:Date of last TB Test:Result of last TB Test:Date of last Hepatitis C Test:Diagnosed Condition (s):Prescription Medication (s):Diagnosed Condition (s):Prescription Medication (s):Diagnosed Condition (s):Prescription Medication (s):Diagnosed Condition (s):Prescription Medication (s):Financial InformationCurrent Source of Income: Wages Unemployment SSI SSDI Worker’s comp VA Savings None Other Check all that apply.If other, explain:Parenting InformationNumber of Children:AgeGenderAgeGenderAgeGenderAgeGenderDCF Involvement? Yes No Date:Worker Name:DCF Office:Worker Phone:Planned Reunification? Yes No Are there custody issues? Yes No Reunification while in program? Yes No Explain:Please complete the following if applicableProbation*until (date):*Parole*until (date):Wrap-up*Wrap date:*Your Application is incomplete without a Bio-Phsycho-Social Evaluation. Please attach a PDF version of your evaluation here.*Max. file size: 100 MB.Statement of ApplicantI hereby certify that all questions above have been answered truthfully.*Initial hereSection BreakInvitation to Self-IdentifyIntroduction: In order to guarantee that all applicants/residents receive the highest quality of care and to ensure the best services possible, we collect data on race and ethnicity. Please select the category or categories that best describes your background. If you choose not to self -identify at this time the federal government allows us to determine this information by visual survey and/or other available information. Refusal to complete this form will not affect your application status. 1. What is your ethnicity?You can specify one or more EthnicityAfrican (specify)African AmericanAmericanAsian IndianBrazilianCambodianCape VerdeanCarribean Islander (specify)ChineseColumbianCubanDominicanEuropeanFilipinoGuatamalanHaitianHonduranJapaneseKoreanLaotianMexican, Mexican American, ChicanoMiddle Eastern (specify)PortuguesePuerto RicanRussianSalvadoranVietnameseOther (specify)Unknown/unspecifiedOther/Specify:2. What is your race?You can specify one or more American Indian/Alaska NativeYesNoA person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.If yes, specify tribal nation:AsianYesNoA person having origins in any of the original a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. Black or African AmericanYesNoA person having origins in any of the black racial groups of Africa. Hispanic or LatinoHispanic/Latino/BlackHispanic/Latino/WhiteHispanic/Latino/OtherA person of Cuban, Mexican, Chicano, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. Native Hawaiian or Pacific IslanderYesNoA person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. WhiteYesNoOther/UnknownOther (specify)UnknownSpecify:3. LanguagesList your primary langage and check all that apply. Primary LanguageLanguages SpokenEnglishArabicCape Verdean CreoleHaitian CreoleSomaliPortugueseChineseRussianSpanishAlbanianKhmerVietnameseOther (specify)Other:4. In what language do you prefer to read health related material?EnglishArabicCape Verdean CreoleHaitian CreoleSomaliPortugueseChineseRussianSpanishAlbanianKhmerVietnameseOther (specify)5. Do you consider yourself to have a disability?YesNo6. Are you currently on a Medicated Assisted Treatment protocol?YesNoIf yes, what type and dose:7. Sexual OrientationHeterosexualHomosexualA-SexualOther (specify)Other:Values StatementsRead our Equal Opportunity & Diversity Statement and Disability Access Notice: https://jeremiahsinn.com/values/ Δ
