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Twelve Month In-House Christian Recovery ProgramPromises of God RecoveryMen's Addiction Recovery ProgramP.O. Box 248Jay, Florida 32565Phone:Application for Consideration of AdmissionName: __________________________________________ Today's Date: _________________Age: ____________ Date of Birth: ___/___/____Current Address: ________________________________ City _____ County _______________ State __________________________ Zip ___________Phone:_________________________ Email: ___________________________Are you associated or related to any POGR staff members or leadership? Yes No If Yes, name and relationship _____________________________________Referred By: ____________________________ Phone: ________________________________Why are you applying to a recovery program at this time?_____________________________________________________________________________________________________________What are your immediate needs?________________________________________________________________________________________________________________________________Family InformationSon/Daughter Age/DOB Responsible Caregiver/Relationship_________________________ _______________ ___________________________________________________________ _______________ ___________________________________________________________ _______________ __________________________________Emergency ContactName:______________________________ Relationship:_____________________________Address: _________________________________City ____________ ST _______Zip ________Phone:________________________ Cell: _________________________________Is there any further information you can offer which might help us in determining youradmission?________________________________________________ _______________________________________________________Alcohol/Drug HistoryPlease fill out the chart completely:SubstanceAmount/HowOften UsedDate StartedDate of Last Use Cocaine / CrackMarijuanaHeroinAlcoholNicotinePrescription DrugMethamphetaminesOtherAge at first use: _________ Longest period of sobriety: __________________________Drug of Choice:______________________________________Previous Treatment Programs? Previous residential treatment centers:Name of Program:_______________________ Admission Date: ________ Discharge Date: ___________Address: ___________________________________ City _____________ ST _______ Zip _________Phone: _____________________________________Name of Program:_______________________ Admission Date: ________ Discharge Date: ___________Address: ___________________________________ City _____________ ST _______ Zip _________Phone: _____________________________________? Outpatient Treatment:Name of Program:_______________________ Admission Date: ________ Discharge Date: ___________Address: ___________________________________ City _____________ ST _______ Zip _________Phone: _____________________________________Name of Program:_______________________ Admission Date: ________ Discharge Date: ___________Address: ___________________________________ City _____________ ST _______ Zip _________Phone: _____________________________________Ongoing HabitsDo you smoke? Yes No Are you willing to quit? Yes NoSuicidal TendenciesHave you ever attempted suicide? Yes No How many times? _____Date Circumstances Treatment Date Diagnosis__________ _______________________ ______________ _________ ____________________________ _______________________ ______________ _________ ____________________________ _______________________ ______________ _________ __________________Do you have current suicidal thoughts? Yes NoIf yes, please describe: _____________________________________________________________ ________________________________________________________________________________Mental Health TreatmentHospitalized for emotional or nervous reasons? Yes NoName Date Chief Complaint Diagnosis _____________________ ______________ ___________________ _______________________________________ _______________ ___________________ __________________Have you ever been in therapy? Yes NoTherapist Type of Therapy Dates_______________________________ __________________________ __________________________________________________ __________________________ ___________________Were medications prescribed? Yes NoIf yes, describe type of medication and dates prescribed and duration: __________________________________________________________________________________________________________________________________________________________________________________Please describe any personal or family psychiatric history: ___________________________________________________________________________________________________________________________________________________________________________________________Abuse HistoryHave you ever experienced any of the following types of abuse?Physical Abuse: _______________Childhood ______________AdultEmotional or Verbal Abuse:_______________Childhood ______________AdultSexual Abuse:_______________Childhood ______________AdultAre you presently in contact with anyone who is I was abusive to you? ____Yes ____NoIf yes, please describe: _________________________________________________________________________________________________________________________________________Legal HistoryHave you ever been arrested? ____Yes ____NoIf yes, how many times? _____Are you a registered sex offender? ____Yes ____NoIf yes, what county and state? ________________________________________________Any Pending Charges: ______ Yes ______ No DateViolationSentence RequirementsCourt Dates PendingAre you on Probation? ____Yes ____No Parole? ____Yes ____No Name, Address, and Telephone Number of Probation I Parole Officer:______________________________________________________________________________________________________________________________________________________________Medical HistoryAre you currently under medical supervision? ____Yes ____No Physician: __________________________________________ Phone: ____________________Address:___________________________________________ Date of last physical: __________Have you ever had any of the following?___Seizures ___ Heart Disease___ Respiratory Problem ___Diabetes ___ Hepatitis___Venereal Disease ___Vision Problems ___Tuberculosis ___ Hearing problems____ Other:_______________________________________________________________ If you checked any of the above, please explain: ___________________________________________________________________________________________________________________Are you currently taking medications? ____Yes ____NoMedication Reason For Taking_______________________________ _______________________________________________________________________________ _______________________________________________________________________________ ________________________________________________Are there any medications you should be taking? ____Yes ____NoIf yes, please explain: ______________________________________________________________________________________________________________________________________________ Have you had any major/minor surgery in the last five years? ____Yes ____NoIf yes, please explain: ______________________________________________________________________________________________________________________________________________ Educational/ Vocational HistoryWhat is your education background: ___High School___ GED ___Some College___ Tech. SchoolAre you a veteran? ____Yes ____No Branch of Service _________________Discharge Type: ___________________________________IncomeAre you currently receiving Medicare, Medicaid, Disability, or Other Government Aid? ____Yes ____No Type and amount?________________________________________Name and Office of Case Worker: __________________________________________________ Are you on food stamps? ____Yes ____No Name and Office of Case Worker: ___________________________________________________Other income source(s): _________________ Amount: $_______ Per: Week/Month/YearName and Office of Case Worker: ___________________________________________________ If selected for residence in this program, is there anything we should know about you thatwould hinder your ability to sweep, mop, lift, mow, or do normal household chores?____Yes ____No If Yes, Explain: _______________________________________________________________ ___________________________________________________________________________Any additional comments you wish to make: ___________________________________________________________________________________________________________________Note: This center is not a medical or psychiatric facility: therefore prospective students must be medically, as well as psychiatrically, cleared prior to admission. The requested medical information within this application for consideration of admission is vitally important and is required before a decision can be rendered as to the appropriateness of our facility for prospective students. If mental health evaluation/documentation is requested, that also must be received before a final decision can be made regarding placement in the recovery program. If within 30 days of admission, it is noted that the client is inappropriate due to medical or psychiatric reasons about which we were uninformed prior, this facilityreserves the right to refer the student to another facility or back to the referring agency.______________________________________________________ ________________________Applicant Signature Date________________________________________________________________________________Biosychosocial AssessmentAre you currently experiencing any of the following??Yes?NoHeadaches?Yes?NoDifficulty Reading?Yes?NoCough?Yes?NoLoss of Sleep?Yes?NoVomiting?Yes?NoConstipation?Yes?NoRecent Weight Loss?Yes?NoShortness of Breath?Yes?NoDifficulty with Coordination?Yes?NoMuscle Cramps or Twitching?Yes?NoWear a Prosthetic Device?Yes?NoBruise Easily?Yes?NoRash?Yes?NoBurning in Urination?Yes?NoWear Glasses or Contacts?Yes?NoUse Hearing Aid?Yes?NoDental Problems?Yes?NoFrequent Indigestion?Yes?NoDiarrhea?Yes?NoAbdominal Pain, Cramping?Yes?NoPalpitations?Yes?NoFacial Numbness?Yes?NoAnkle Swelling?Yes?NoNeck, Shoulder, Back Pain?Yes?NoSores Difficult to Heal?Yes?NoCurrent Injuries?Yes?NoBlood in Urine?Yes?NoUnusual DischargeAre you currently experiencing any of the following??Yes?NoWithdrawl from Alcohol?Yes?NoDelirium Tremens (DT's)?Yes?NoMumps?Yes?NoScarlet Fever?Yes?NoKidney Problems?Yes?NoArthritis?Yes?NoMental Illness?Yes?NoPositive TB Skin Test?Yes?NoHerpes?Yes?NoWithdrawl From Drugs?Yes?NoMeasles?Yes?NoChicken Pox?Yes?NoLiver Problems?Yes?NoUlcers?Yes?NoHeart Disease?Yes?NoTuberculosis?Yes?NoGonorrhea?Yes?NoAidsPLEASE GIVE A LITTLE BACKGROUND ABOUT YOURSELF AND WHY YOU FEELTHIS IS THE RIGHT PROGRAM FOR YOU.????????????????????????????? ................
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