CROSSROADS ENROLLMENT APPLICATION (Please carefully read and print all answers. All blank spaces must be filled.)

Transcription

1 P a g e 1 CROSSROADS ENROLLMENT APPLICATION (Please carefully read and print all answers. All blank spaces must be filled.) Personal Information Today s Date: Name: First: M.I.: Last: Preferred Name: Maiden Name: Date of Birth: / / SSN #: Referral Type Self, Family, Friends Private Practitioner (Psychiatrist/MD) Community Mental Health Center County/Local Hospital Another Clubhouse State Social Services County Social Services Vocational Rehab Shelter for the Homeless Mental Health Court Other: 2. Referring Agency: Applicant s Mailing Address: City: State: Zip: Permanent Address: City: State: Zip: Phone: ( ) Alternative Phone: ( ) 1. Housing Type Own Home/Apartment (Non-subsidized) Home of a family member (shared responsibility) Home of a family member (dependent on family Temporary Housing Supported apartment Supervised housing Group home Psychiatric Hospital Nursing Home Prison/Jail Homeless Home of a friend Other (please specify): 2. Housing Status Alone With Roommate(s)/ Housemate(s) With Parent(s) With Other Adult Relative(s) With minor child(ren) With Partner With Partner and Child(ren) Institutional setting 3. Housing Satisfaction Very Satisfied Somewhat Satisfied Neutral Somewhat Unsatisfied Very Unsatisfied

2 P a g e 2 4. Social Interaction: Do you have a close friend you can talk to? Yes No Do you have frequent conflicts with friends (more than once per month)? Yes No Are you satisfied with your family relationships? Yes No Do you have conflicts with your family members (more than once per month)? Yes No Do you feel isolated? Yes No 1. Gender: Male Female Other (please specify) 2. Ethnicity: African American American Indian/Native American Asian Caribbean Caucasian Latino/Hispanic Middle Eastern Pacific Islander 3. Language: English 4. Marital Status Primary Other (please specify) Single, Never Married Widowed Permanent Partner Divorced Separated Married 5. Number of Minor Children: 6. Primary Weekday Activity Independent Employment Clubhouse Work Parenting/Care Taking at Home Other Volunteer Work School-High School Day Program Outside of the Clubhouse School-Trade School/College In Hospital/House Bound Psychiatric Reasons Transitional Employment No Structured Daytime Activity Enclave Work Sheltered Workshop 7. Primary Reasons for wanting to attend Crossroads? 8. Education Level: Less than High School GED High School Diploma Trade School/Vo Tech Some College Associate s Degree Bachelor s Degree Some Graduate Work Master s Degree Advanced Graduate 9. Do you have outstanding student loans? 10. Are you interested in continuing your formal education? 1. Current Employment Full Time (32 hours per week or more) Part Time (Less than 32 hours per week Day Labor (Selected to work each day at employment agency) Contract Labor (Selected to work on jobs or projects for a limited period of time) No job at this time and I am not looking. No job at this time and I am looking for employment

3 P a g e 3 2. Job held the longest: 3. Income Source(s) Type of Income Wages-Independent Employment Local Assistance (County/State) Wages-Transitional Employment AFDC Wages-Supported Employment Veteran s Benefits Wages-Shelter Workshop Retirement Benefits SSDI Family Support SSI Friend Support General Assistance (State) Financial Support Other (please specify): 4. Total Amount of Monthly Income: 5. What type of work would you like to do? 1. Medical Alerts- Check all that apply. Chronic Physical Illness Severe Allergic Reactions Deaf/Hearing Impairment New Psychiatric Medication Blind/Vision Impairment Recent Surgery Epilepsy/Seizure Diabetes Asthma Hypertension Other Physical Disability: (please specify) 1. Emergency Contact Information: Name: Relationship to Applicant: Telephone: 2. Treatment Provider: Name: Agency: Address: Telephone: Release? (Y/N): 1. Has applicant ever been convicted of a misdemeanor? Yes 2. Has applicant ever been convicted of a felony? Yes 3. Please, explain: 4. Does (s)he have a history of violent behavior toward others? Yes

4 P a g e 4 1. Medical Insurance Policy(s): Check all that apply. Policy Type Medicaid Veteran s Benefits Medicare Worker s Compensation Medicare, Managed Care Family Pay Private Insurance Self-pay (no insurance) Other (please specify): 2. Last Medical Exam: MM/DD/YYYY: 3. Last Dental Exam: MM/DD/YYYY: 4. Nutrition: Number of meals per day: Special dietary needs: 5. Exercise: 30 mins per day 30 mins weekly 30 minutes three times per week I do not exercise 6. Are you currently taking prescribed medications or over the counter medications, natural remedies or vitamins and minerals? Yes 7. If you are female, are you currently pregnant? Yes 8. Are you taking your medications as prescribed? Yes Other (please specify): 9. Psychiatric History Total Number of Hospital Admissions: Estimate Total Months of ALL Hospitalizations: Length (months) of LONGEST Hospitalization: To the best of my knowledge the above information is accurate. Signature of Applicant: Date:

5 P a g e 5 Pages 5 and 6 must be filled out by a treatment provider. Name of Applicant (please print): Applicant s Date of Birth: 1. Primary Diagnosis Schizophrenia Major Depression Schizoaffective Disorder Other Psychotic Disorder Bi-Polar Disorder Other Major Mental Illness If other was selected, please specify: 2. DSM IV Axis I 3. DSM IV Axis II 4. DSM IV Axis III 5. DSM IV Axis IV 6. DSM IV Axis V 7. History with Alcohol Yes No Has applicant had a problem with alcohol? Has applicant been in treatment for an alcohol problem? Is applicant currently in treatment or in a support group? Does (s)he want help with an alcohol problem? How long has (s)he been clean and sober?: 8. History with Drugs Yes No Has applicant had a problem with drugs? Has applicant been in treatment for a drug problem?

6 P a g e 6 Is applicant currently in treatment or in a support group? Does (s)he want help with a drug problem? How long has (s)he been clean and sober?: 9. Drug/Alcohol Notes (Include Type of Drug, Amount, frequency): 10. Are you aware of any violent behaviors or incidences that the applicant exhibits or has been involved in? Yes 11. If yes, please describe: Referral Source Name and credentials: Referring Agency: Telephone Number: Signature: Date: