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 Agency Use 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 Other Attorney 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: Phone MedicationsMedication Name Dose Last taken Medication Name Dose Last taken Medication Name Dose Last taken Medication Name Dose Last taken Have 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 Treatment Where Outcome Date of Treatment Where Outcome Date of Treatment Where Outcome Do 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 Use Alcohol - Last Use Alcohol - Frequency Alcohol - Usual Route Cocaine - Age of First Use Cocaine - Last Use Cocaine - Frequency Cocaine - Usual Route Crack - Age of First Use Crack - Last Use Crack - Frequency Crack - Usual Route Marijuana/Hashish - Age of First Use Marijuana/Hashish - Last Use Marijuana/Hashish - Frequency Marijuana/Hashish - Usual Route Heroin - Age of First Use Heroin - Last Use Heroin - Frequency Heroin - Usual Route Non Rx Methadone - Age of First Use Non Rx Methadone - Last Use Non Rx Methadone - Frequency Non Rx Methadone - Usual Route Other Opiates - Age of First Use Other Opiates - Last Use Other Opiates - Frequency Other Opiates - Usual Route PCP - Age of First Use PCP - Last Use PCP - Frequency PCP - Usual Route Other Hallucinogens - Age of First Use Other Hallucinogens - Last Use Other Hallucinogens - Frequency Other Hallucinogens - Usual Route Methamphetamine - Age of First Use Methamphetamine - Last Use Methamphetamine - Frequency Methamphetamine - Usual Route Other Amphetamines - Age of First Use Other Amphetamines - Last Use Other Amphetamines - Frequency Other Amphetamines - Usual Route Other Stimulants - Age of First Use Other Stimulants - Last Use Other Stimulants - Frequency Other Stimulants - Usual Route Benzodiazepines - Age of First Use Benzodiazepines - Last Use Benzodiazepines - Frequency Benzodiazepines - Usual Route Other Tranquilizers - Age of First Use Other Tranquilizers - Last Use Other Tranquilizers - Frequency Other Tranquilizers - Usual Route Barbiturates - Age of First Use Barbiturates - Last Use Barbiturates - Frequency Barbiturates - Usual Route Other Sedatives/Hypnotics - Age of First Use Other Sedatives/Hypnotics - Last Use Other Sedatives/Hypnotics - Frequency Other Sedatives/Hypnotics - Usual Route Inhalants - Age of First Use Inhalants - Last Use Inhalants - Frequency Inhalants - Usual Route Over-the-Counter - Age of First Use Over-the-Counter - Last Use Over-the-Counter - Frequency Over-the-Counter - Usual Route Ecstasy - Age of First Use Ecstasy - Last Use Ecstasy - Frequency Ecstasy - Usual Route Nicotine - Age of First Use Nicotine - Last Use Nicotine - Frequency Nicotine - Usual Route Caffeine - Age of First Use Caffeine - Last Use Caffeine - Frequency Caffeine - Usual Route Other - Age of First Use Other - Last Use Other - Frequency Other - Usual Route Other - Age of First Use Other - Last Use Other - Frequency Other - Usual Route In 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: Age Gender Age Gender Age Gender Age Gender DCF 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 Language Languages 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
