Phone # 907-696-2744 or 907-727-0826
Admissions Application
Please print form
out, and answer every question to the best of your ability. The questions may
seem very personal in nature but it is our desire to help you as much possible while
you are here. All information contained in this file is considered confidential
and will not be made available to anyone without a court order or signed
release. Mail form to:
Personal Information
Name: ______________________________________________________Age:__________
Address: __________________________________________________________________
City: ___________________________________________State:______________________
Nationality: _____________________________________Birth Date: __________________
Phone #s: _______________________________________S.S. #:______________________
Are you a U.S. Citizen: _________?
Person to Contact the case of an emergency: ______________________________________
Their Phone #:______________________________________________________________
Their relationship to you: _____________________________________________________
Necessary
Information
Who referred you to the Lydia House? __________________________________________
What is your reason for entering this Program? ___________________________________
Do you have a valid driver’s License? _________ Your License or ID # is______________
Do you have any medical insurances if so who or what? _____________________________
If you know your policy number please list: _______________________________________
Are you employed or receiving unemployment? ____________________________________
Are you receiving SSI, SSDI, Corporation dividends, Food Stamps or any other kind of financial assistance? ___________please Describe__________________________________
Please list amount received: ____________________________________________________
Educational
Information
Highest grade completed: ________ or GED: Yes or No When if completed? __________
Page 1
Do you have any learning disabilities? Yes or No
Please explain: ______________________________________________________________
___________________________________________________________________________
Do you have any Technical/vocational/college schooling? ______________________________________________________________________________________________________________________________________________________
Have you ever served in the military? Please explain:
______________________________________________________________________________________________________________________________________________________
Family Information
Marital Status: Please check all that applies:
Single____ Married____ Separated____ Divorced____ Widowed____
Living w/ some one_____
Do you currently have a boyfriend_____ Yes or No His name:________________________
If married please write their name________________ Date of marriage:_________________
Address:
Describe your relationship with your spouse:_______________________________________
___________________________________________________________________________
Ex-spouse’s name and address: _________________________________________________
___________________________________________________________________________
How many children do you have? ________________ List names of children:
Name: _________________________________________________________Age: _______
Current Caretaker: ___________________________________________________________
Name: _________________________________________________________Age:________
Current Caretaker: ___________________________________________________________
Name: _________________________________________________________Age:________
Current Caretaker: ___________________________________________________________
Name: ________________________________________________________ Age: ________
Current Caretaker: ___________________________________________________________
Do they have a Social Worker? Yes or No Their name______________________________
Address: _____________________________________Phone:________________________
Page 2
Parents: (please note if deceased)
Father’s name: ________________________________Phone:_________________________
Address: ____________________________________City: _____________ State_________
Mother’s name: _______________________________ Phone: ________________________
Address: _____________________________________City ____________ State_________
Are your parents: married____ divorced____ separated____remarried______ widowed_____
Describe your relationship with your Mother: ______________________________________
___________________________________________________________________________
Describe your relationship with your Father: ______________________________________
___________________________________________________________________________
Name and address of Step Parents: ______________________________________________
___________________________________________________________________________
Describe your relationship with your step Parents: __________________________________
___________________________________________________________________________
As a child who did you feel closest to? Father ____ Mother ____ someone else_____
List names and relationship of those you lived with: ________________________________
How long did you live with them? _____ Explain why you lived with them _____________
___________________________________________________________________________
Do either of your parents have a current or past history of substance abuse? Yes or No
Please Explain ____________________________________________________________
_________________________________________________________________________
List names and ages of your brothers & sisters: ____________________________________
___________________________________________________________________________
Step brother & sisters: ________________________________________________________
List any other family members who drink alcohol or use drugs: _______________________
___________________________________________________________________________
Page 3
SEXUAL HISTORY: please mark which apply to you:
Heterosexual ____ Homosexual____ Bisexual ____ Transsexual____
Have you ever been involved in a homosexual relationship or activities? Yes or No
Please explain_______________________________________________________________
___________________________________________________________________________
Have you ever committed adultery? Yes or No
Have you ever been involved in prostitution? Yes or No If yes how long? _______________
Have you ever been sexually abused? Yes or No Have you ever been raped? Yes or No
At what age(s) _____________________________ By whom_________________________
Is there a chance that you might be pregnant? Yes or No
Employment history
What is your trade/profession, if any? ____________________________________________
Name of last employer? _______________________________________________________
Type of work: _______________________________________________________________
Reason for leaving: __________________________________________________________
What career, job, or trade would you like to do in the future? _________________________
What type of skills do you have? ________________________________________________
Legal History
Have you ever been arrested? Yes or No List your 3 most recent arrests and charges:
Date: _________ Charges: _____________________________________________________
Sentence: Jail Probation How long: ____________________________________________
Date: _________ Charges: _____________________________________________________
Sentence: Jail Probation How long: ____________________________________________
Date: _________ Charges: _____________________________________________________
Sentence: Jail Probation How long: ____________________________________________
Are you currently on: Probation: Yes or No Parole: Yes or No
Time remaining: _____________________ Probation/Parole officers name: _____________
Address: ________________________________________________ Phone: ____________
Name of lawyer: _________________________________________ Phone: _____________
Do you have any?
Page 4
Upcoming court dates: Yes or No Explain: ________________________________________
Outstanding warrants: Yes or No Explain: ________________________________________
Fines or costs that you owe: Yes or No Explain: ____________________________________
Personality and Mental
Health
Self description: (please circle the characteristics that apply to you)
Gentle Stern Happy Loving Distant Sensitive Kind Angry Caring Loyal Nice Demanding Stubborn Lonely Bold Gracious Talkative Independent Critical Meek Positive Impatient Joyful Forgiving Leader Strong Passive Moody Encouraging Controlling Energetic Fearful Trustworthy Shy Quiet Humorous Content Weak Short-tempered Calm Easily influenced Impulsive
If was in an institution: Name: _________________________________________________
Address: ___________________________________________________________________
Please explain: ______________________________________________________________
___________________________________________________________________________
Have you ever had an eating disorder? Anorexia ____ Bulimia____ Over-eating____
Have you ever attempted suicide? Yes or No How? _______________________________
Physical Health
History:
Do you have any medical or dental problems? Yes or No If yes explain: _________________
______________________________________________________________________________________________________________________________________________________
What provisions, if any have been made for medical expenses through family or sponsor? ___________________________________________________________________
Do you wear glasses or contact lenses? Yes or No Date of last eye exam_________________
Are you currently on any medications? Yes or No List medications and reason for taking it: ________________________________________________________________________
Page 5
Do you have any past or current medical problems (surgeries, dietary requirements, sexually transmitted diseases, seizures, allergies) that may affect you while you are in the program?
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Are there any physical problems that would limit you from participating in all aspects of the program? ___________________________________________________________________
Lydia House is not a medical treatment facility and is unable to provide 24 hour on site medical supervision. If a resident’s health deteriorates to the point where she is no longer able to participate in the daily activities of the program, that person will have to leave the program to take care of their medical needs. Re-entry to the program will be dependant on a written release from their doctor.
Drug/Alcohol/Substance
Abuse History:
First drug of choice: __________________2nd________________3rd__________________
Age of first use: _____________________ __________________ _____________________
How taken: _________________________ ___________________ ____________________
What drugs were you using just before you came into the center? ______________________
If you did drink alcohol what age did you start? ____________________________________
Who introduced you to drugs/alcohol? ___________________________________________
How many times have you attempted to stop using? _________________________________
What methods did you use to stop? ______________________________________________
___________________________________________________________________________
Why did you start using again? _________________________________________________
How long have you been using since you last stopped? ______________________________
Longest period clean: _________________________________________________________
Have you had contact with: AA? Yes or No NA? Yes or No
What drugs have you used? (please circle all that apply)
Heavy alcohol Barbiturates (downers) Amphetamines (uppers) Heroin Cocaine LSD Hallucinogenic Opium Methadone Marijuana Tobacco Crack Inhalants Hashish Prescription Medicine Methamphetamine (speed) Morphine Glue Light alcohol
Page 6
List other substances: _________________________________________________________
I depended on drugs to: (circle all that applies)
A. To cope with life B. For pleasure C. To escape reality D. To be with the “in” crowd
Other reasons_______________________________________________________________
Do you smoke tobacco? Yes or No Do you chew tobacco Yes or No
How old were you when you started to smoke? ________ Chew? _______
Are you aware that tobacco use is not permitted while in the program? Yes or No
The Problem:
Why did you come here?
______________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Have you ever been in any inpatient for outpatient programs? Yes or No please list the programs: __________________________________________________________________
______________________________________________________________________________________________________________________________________________________
What is the longest you have stayed in another program and why did you leave? __________
___________________________________________________________________________
What areas do you need to work on in your life? ___________________________________
___________________________________________________________________________
Why do you feel you are ready to make change in your life? __________________________
___________________________________________________________________________
What would you like to do after you
leave the Lydia House? __________________________
___________________________________________________________________________
Spiritual Life:
Do you know that this is a Christian oriented program? Yes or No
What is your religious affiliation? _______________________________________________
Have you ever committed your life to God? Yes or No
Have you ever received Jesus Christ as your Savior? Yes or No The date this happened________ Where did this take place? ___________________________________
Did you attend church as a child? Yes or No Name of church__________________________
Page 7
What church have you attended as an adult? _______________________________________
Have you ever been involved in Satanism, witchcraft, or occult activity? Yes or No
Please explain: ______________________________________________________________
Have you ever been a follower of Jehovah witnesses? Yes or No
Have you ever been a member of any other cult? Yes or No Name of places______________
___________________________________________________________________________
What is your opinion or view of God? ____________________________________________
______________________________________________________________________________________________________________________________________________________
Page 8
THIS PAGE IS TO BE COMPLETED BY STAFF
Name of resident: ____________________________________________________________
Interviewing staff: ___________________________________ Date: __________________
Note any questions the resident refused to answer and state the reason given: _____________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Any other comments: _________________________________________________________
___________________________________________________________________________
Page 9