Intake form can be downloaded below and emailed to: heidi_krny@yahoo.com or
mailed to: 7780 49th St N Suite 208
Pinellas Park, FL, 33781
mailed to: 7780 49th St N Suite 208
Pinellas Park, FL, 33781
| simplyhope_intake_form.docx |
Sample Form:
Today’s Date:
Name: Cell Phone #:
DOB: ___/___/_____ SS#:______________ Gender: 0 Male 0 Female
ON NARCOTICS? : __________ ON PSYCHOTROPIC MEDS ?:_________
Marital Status: 0 Single 0 Married 0 Separated O Divorced
Emergency Contact: _____________________ Relationship: ________
Address: ______________________________ Phone#: ____________
Do you have any children? 0 No 0 Yes If yes, how many? ____
Who has custody of the children? ______________________________
Are you court ordered to pay child support? 0 No 0 Yes
If so, do you have a copy of the order? 0 No 0 Yes
Are you currently employed? 0 No 0 Yes How long? __________
If yes, where? ____________________________________________
(Need copy of most recent pay stub)
Are you a resident of Pinellas, Pasco, Manatee, Hillsborough, or Sarasota Counties? 0 No 0 Yes
If yes, for how long? _____________ Which County? ______________
Are you homeless? 0 No 0 Yes
For how long? ________________ Number of times: __________
Are you a veteran? 0 No 0 Yes If yes, type of discharge?_________
Do you receive benefits? 0 No 0 Yes
Are you disabled? 0 No 0 Yes If yes, describe: ____________________
Do you have any infectious diseases? 0 No 0 Yes
If yes, list them: __________________________________________
Do you have an existing medical condition? 0 No 0 Yes
If yes, please explain: _______________________________________
Highest Level of Education?
0 Incomplete HS 0 HS Graduate 0 Some College 0 College Graduate
Do you have a valid driver’s license? 0 No 0 Yes
If yes, state issued and number: ________________________________
Are you a US Citizen? 0 No 0 Yes
Have you ever tried AA or NA before? 0 No 0 Yes
Do you have friends/relatives living now or have ever lived in a Simply Hope house? 0 No 0 Yes
If yes, who? _________________________ Relation: ___________
Probation with D.O.C. 0 No 0 Yes
Probation Officer: ___________________________ Phone:_________
Which treatment facility were you in prior to coming to Simply Hope transitional housing? ______________________________________
Contact person for facility: ________________ Phone #: ___________
How did you hear about us?___________________________________
Client Signature __________________________________________
Client Printed Name ________________________________________
Substance Use History
Name: _______________________________ Date: ______________
Provide the date and type of last substance abuse and/or use of any kind. Include any and all illegal, legal, prescription or non-prescription (over-the-counter) drugs. Include those regularly taken and prescribed under a doctor’s care. ALCOHOL IS A DRUG and must be included.
SUBSTANCE: DATE OF LAST USE:
______________________ _______________________
______________________ _______________________
______________________ _______________________
______________________ _______________________
______________________ _______________________
______________________ _______________________
______________________ _______________________
______________________ _______________________
______________________ _______________________
______________________ _______________________
Signature of Client: ____________________________ Date: _________
Name: Cell Phone #:
DOB: ___/___/_____ SS#:______________ Gender: 0 Male 0 Female
ON NARCOTICS? : __________ ON PSYCHOTROPIC MEDS ?:_________
Marital Status: 0 Single 0 Married 0 Separated O Divorced
Emergency Contact: _____________________ Relationship: ________
Address: ______________________________ Phone#: ____________
Do you have any children? 0 No 0 Yes If yes, how many? ____
Who has custody of the children? ______________________________
Are you court ordered to pay child support? 0 No 0 Yes
If so, do you have a copy of the order? 0 No 0 Yes
Are you currently employed? 0 No 0 Yes How long? __________
If yes, where? ____________________________________________
(Need copy of most recent pay stub)
Are you a resident of Pinellas, Pasco, Manatee, Hillsborough, or Sarasota Counties? 0 No 0 Yes
If yes, for how long? _____________ Which County? ______________
Are you homeless? 0 No 0 Yes
For how long? ________________ Number of times: __________
Are you a veteran? 0 No 0 Yes If yes, type of discharge?_________
Do you receive benefits? 0 No 0 Yes
Are you disabled? 0 No 0 Yes If yes, describe: ____________________
Do you have any infectious diseases? 0 No 0 Yes
If yes, list them: __________________________________________
Do you have an existing medical condition? 0 No 0 Yes
If yes, please explain: _______________________________________
Highest Level of Education?
0 Incomplete HS 0 HS Graduate 0 Some College 0 College Graduate
Do you have a valid driver’s license? 0 No 0 Yes
If yes, state issued and number: ________________________________
Are you a US Citizen? 0 No 0 Yes
Have you ever tried AA or NA before? 0 No 0 Yes
Do you have friends/relatives living now or have ever lived in a Simply Hope house? 0 No 0 Yes
If yes, who? _________________________ Relation: ___________
Probation with D.O.C. 0 No 0 Yes
Probation Officer: ___________________________ Phone:_________
Which treatment facility were you in prior to coming to Simply Hope transitional housing? ______________________________________
Contact person for facility: ________________ Phone #: ___________
How did you hear about us?___________________________________
Client Signature __________________________________________
Client Printed Name ________________________________________
Substance Use History
Name: _______________________________ Date: ______________
Provide the date and type of last substance abuse and/or use of any kind. Include any and all illegal, legal, prescription or non-prescription (over-the-counter) drugs. Include those regularly taken and prescribed under a doctor’s care. ALCOHOL IS A DRUG and must be included.
SUBSTANCE: DATE OF LAST USE:
______________________ _______________________
______________________ _______________________
______________________ _______________________
______________________ _______________________
______________________ _______________________
______________________ _______________________
______________________ _______________________
______________________ _______________________
______________________ _______________________
______________________ _______________________
Signature of Client: ____________________________ Date: _________