Hope for Tomorrow, Inc. Application for Residency

PLEASE ANSWER ALL QUESTIONS

To ensure that information is as accurate and complete as possible, application must be filled out by the applicant and not a parent, spouse, fiancé, brother or sister, or other family member or friend.


If your not sure of an answer,
select the option that fits best
.

Our mission is to help the chronic substance abusing, chemically dependent, and/or compulsive pathological gambler develop into what they are capable of becoming, and to ultimately develop a life based upon truth, goodness, wholeness, justice and order, richness and totality, and autonomy and self-sufficiency.

We accomplish our mission by providing innovative, comprehensive and individualized educational services, in conjunction with a highly structured, sober, and safe permanent supportive living environment. Hope for Tomorrow, Inc. is committed to the belief that incorporating a holistic approach to substance abuse produces

an accountable, responsible, productive lifestyle.

We provide professional clinical services to individuals regardless of race, ethnicity, age, creed, sex, sexual orientation, HIV/AIDS status, or financial ability to pay.

Any information provided and/or gathered, either with an answer or by not answering a question is used strictly by Hope for Tomorrow, Inc. to determine appropriateness for placement in certain programs and/or for a referral to other programs and/or services. All information is confidential and will not be shared with another person or agency unless a signed and dated release of information is provided by you.

 

Please do not print this form. Data is only accepted electronically.

 


 

 

Date of application

  

Where to contact. i.e. home, parents house... If in treatment - where?

Emergency Contact Name And Number: By providing this information you are authorizing Hope for Tomorrow to make contact for purposes of admission only - no diagnostic or confidential information will be shared.

 
If in treatment, what is your expected release date?

Last Name

 

First Name

 

Date of Birth

Age

Sex

  Male               Female

SS Number

  123456789 Numbers Only No Dashes

Street Address

City

State/Province

Zip/Postal Code

County (not country)

Cell Phone

1234567890 Numbers Only No Dashes

Home Phone

1234567890 Numbers Only No Dashes

E-mail

 

1. Race. 

  1B. Ethnicity.   

1C. Primary Language.   

 

2. Select the one that best describes your religion: 

 

3. Drivers License or State ID Number. 

 

4. Is drivers license valid?   Yes No

 

5. Marital status: 

 

6. Number of dependants, including yourself?                                                        

 

6B. Number of children living with you and / or for whom you are the primary care giver. Do not include children who have been placed by DCFS, temporarily or permanently with others for their care, whether relatives or other foster care?   

 

7. What is your sexual orientation?  

 

 

8. Are you interested in family counseling ?    Yes No

 

 

9. Veteran status: 

 

 

10. Last zip code you resided in? 

 

 

11. Last town you resided in? 

 

 

12. Last county (not country) you resided in?                                     

 

 

13. Health insurance status: 

 

 

14. Employment status (now - today, not previous):

 

14B. If "Not in Labor Force" was selected above, provide detail here.

 

15. Name of employer? 

 

 

16. Employer phone number?    1234567890 Numbers Only No Dashes

 

 

17. Type of employment (Current or last)? 

 

 

18. Length of current employment or unemployment status?  

 

 

19. Annual income (now - today, not your previous income)

 

 

20. Income source?: 

 

 

21. Are you currently receiving SSI or any other public aid?   Yes   No

 

 

22. Highest grade completed? 

 

 

23. Are you currently a student? Yes No

 

 

24. Previous treatments attempts including detox(s)?                                             

 

 

25. Primary drug of choice? 

Age of first use.  

 

Date of last use?

 

Frequency of use - prior to treatment or current abstinence?  

 

Primary drug route of administration?  

 25B. Were you ever an IV drug user?       Yes   No

 

 

26. Secondary drug of choice? 

Age of first use.

 

Date of last use?

 

Frequency of use - prior to treatment or current abstinence?  

 

Secondary drug route of administration? 

 

 

27. Tertiary or third drug of choice?   

Age of first use.

 

Date of last use?

 

Frequency of use - prior to treatment or current abstinence?  

 

Tertiary drug, route of administration? 

 

 

28. Do you use - more, less, or about the same as you did when you first started using your primary drug of choice?    

More     Less      Same      NA

 

 

29. Within the last twelve months, have you EVER discovered that it was hard to stop using once you began or that you used your drug of choice even when you said you wouldn't.   Yes   No   NA - Veteran

29B. Within the last twelve months, if you have experienced adverse consequences (health, marital, legal, occupational, financial, etc...), did you continue to use your drug of choice despite these adverse consequences?
  Yes   No
   NA - Veteran

 

29C. What would your typical relapse pattern look like.

 

 

 

30. Have you ever witnessed or been the victim of a violent crime or act?

          Yes   No

30B. Have you ever been abused physically, emotionally, or sexually?

Yes   No

 

If yes to either, explain. (75 character maximum)

 

 

31. Other compulsions? Select any of the following options that apply:

Sex        	  
Gambling      
Internet use   	 
Eating
Anorexia    	  
Bulimia        	
Spending       	 
Self Mutilation
OCD (Obsessive Compulsive Disorder)

 

 

32. Do you have any physical conditions or complications?    Yes No

(75 character maximum)

If yes, what?  

 

 

33. Name of physician or regular family doctor. 

 

 

34. Date of last physical? (If not sure, approximate at least month and year.)

  

 

 

35. List any medications you are currently taking. (100 character maximum)

 

 

36. List any allergies you have.  (50 character maximum)

 

 

37. Beside applying to Hope for Tomorrow, Inc. what action steps are you taking to remain sober?  (75 character maximum)

 

 

 

38. If you have been or are currently experiencing homelessness, please check each area that would assist you in securing sober, independent living. Select all that apply.

Sub. abuse / Mental health treatment            	  
Legal assistance 
Employment services     			  
Spiritual
Physical, emotional, or sexual abuse counseling  	  
Social Security card 
Financial services     				  
Education 
Life skills                                     		  
Recreational
ID's                    				  
Transportation

 

 

39. In the past 3 years, how many times have you been in the position to be considered homeless? (Homeless can be defined as not having a permanent mailing address (e.g., shelters, treatment centers, jails, institutions, hotels/motels, friends/families house are all considered homeless).  

 

 

40. Are you currently homeless?     Yes No

40B. Current living Arrangement.

 

 

40C. Are you receiving or have you received services from any of these agencies within the last three years? - If you used more than one, select the one you used most recently or most often.
  

 

 

41. What were some of the places you have lived. Select any of the following options that apply:

Treatment center
Jail or prison
Hotel or motel
Friends or relatives house
Streets
Hospital / Institution
Shelter

 

 

42. In the past 2 years, what is the longest period of time that you have abstained from using alcohol and/or drugs (outside of a structured residential environment)?

 

 

 

43. How long can you normally stay sober before you relapse?  

(35 character maximum) 

 

44. In your lifetime have you EVER had a withdrawal seizure?     Yes  No

 

44B. Are you currently experiencing any of the following signs of withdrawal? Select any of the following options that apply:

Shakes      	  	
Nausea          	
Fever           	
Chills
Seizures      		
Sweats          	
Vomiting       	
Tremors
Cramps      		
Hallucinations  
 

 

 

45. What are your relapse triggers? Select any of the following options that apply:

Impulsiveness                       		
Low self-esteem                          
Guilt                    			
Shame                                  
Anger                               		
Resentments                              
Depression              			
Stress                                 
Isolation                           		
Financial/Money                          
Lack of support network  		
Inability to ask for help              
Insufficient spiritual connection   	
Quit doing the maintenance for sobriety  
Boredom                  			
Loneliness                             
Relationships                       		

 

 

46. Do you smoke?  Yes No

 

 

47. Do you drink caffeinated products?  Yes No

 

 

48. WOMEN - Are you pregnant?  Yes No

If yes, how far along?  (35 character maximum)

 

Do you have prenatal care?     Yes No

 

49. Do you have any close friends that DO NOT use substances?     Yes No

 

 

50. Addiction involves a lot of very high risk behaviors that are similar to gambling. Such as driving while drunk/impaired or putting yourself in "possible" harmful situations. (i.e.) unprotected sex, bad neighborhoods or people. Do you feel you may have a gambling problem?   Yes No

 

 

51. Have you ever been diagnosed with any of the following? Select any of the options that apply:

Depression                         		
Bi-polar          
Anxiety        				
Borderline personality disorder
Antisocial personality disorder    	
Schizophrenia     
Seizures       				
Obsessive compulsive disorder	(OCD)
Narcissistic personality disorder
ADD / ADHD

 

 

52. What are your spiritual beliefs? (75 character maximum)

 

 

 

53. Have you ever had suicidal thoughts while not under the influence?  Yes No

Any under the influence?   Yes No

Are they current?  Yes No

 

If yes to any of the above, do you or did you have a plan?    Yes No

 

Describe.  (50 character maximum)

 

When was the last suicide thought, and describe.

(75 character maximum)

 

 

54. Have you ever had homicidal thoughts?     Yes No

Are they current?  Yes No

 

Describe the homicidal thoughts. (75 character maximum)

 

 

55. Are you connected to a MISA (Mental Illness Substance Abuse) case worker?

  Yes No

 

If Yes MISA case worker name and location. (50 character maximum)

 

 

56. Any psychiatric hospitalizations?

Yes No

 

If yes, how many in the last 2 years?  

 

 

57. Any hallucinations not drug induced?

Yes No

 

If yes, describe. (75 character maximum)

 

 

58. Do you experience periods of low moods or extreme sadness?

Yes No

 

If yes, are the current?   Yes No

If yes to either, describe the moods or sadness. (75 character maximum)

 

 

59. Do you, or have you ever had, difficulty controlling your anger?

Yes No

 

 If yes, is this current?   Yes No

 

 Describe. (75 character maximum)

 

60. Have you EVER been involved in a street gang?  Yes No

If yes, what gang and when? (50 character maximum)

 

 

61. Do you think you have a problem with alcohol or drugs?  Yes No  Unsure  NA -Veteran

Why do you think this? (75 character maximum)
 61B.

 

 

62. Why do you want to stay clean now? (75 character maximum)

 

 

 

63. What are some specific consequences you have encountered as a result of your

substance use?  (75 character maximum)

          

 

 

64. What benefits do you feel that sobriety will bring to you? (75 character maximum)

 

 

 

65. Have you ever been charged with or convicted of a violent crime?  Yes No

 
65B. Have you ever been charged with or convicted with a crime against a child?

  Yes No

If yes to either of these last two questions, describe. (75 character maximum)

 

 

66. Do you have any family members that have been or are addicted to alcohol or drugs? Select all that apply.

Mother           
Father          
Siblings         
Aunts or uncles
Grandparents

 

 

67. What area(s) of your life are causing you the most emotional, mental and/or spiritual pain? Select any of the following options that apply:

Work            		
Money      	 
Family         
Relationships
Self-esteem   	
Past         	 
Legal/court

 

 

68. Goal number one for the next six months? 

 

 

69. Number two goal for the next six months. 

 

 

70. Number three goal for the next six months. 

 

 

71. Number of criminal convictions? (Including DUI) If none enter "0" zero. 

71B. Number of arrests in the last 30 days? 

 

 

72. Criminal convictions and /or charges. Select any of the following options that apply:

Possession of a controlled substance   	
Possession of paraphernalia     
Theft                         			
Retail theft
Assault                                	
Domestic violence               
Sexual assault                		
Sexual abuse
Child abuse                            	
Child neglect                   
Criminal damage to property   		
Reckless driving
DUI (1)                                	
DUI (2)                         
DUI (3 or more)               		
Driving on a revoked license
Driving on a suspended license       	
Forgery                         
Burglary                      			
Escape
Prostitution
Auto theft

 

 

73. Are you connected with DCFS?    Yes No

 

 

74. Are you currently on probation or parole?  Yes No

If yes, what county?  

 

Probation or parole agents name.  

 

 

75. Any cases pending or warrants?    Yes No

 If yes. what? (50 character maximum)

 

 

76. Next court date?     -- mm/dd/yy As Shown

 

 

77. Are you currently living in or do you have a safe, sober living environment to return to?

Yes No

 

 Explain. (50 character maximum)

 

 

 

78. Describe what the following sentence means to you. "Building your life around your recovery instead of building your recovery around your life."®  (150 character maximum)

 

 

 

79. Hope for Tomorrow, Inc. has certain expectations of its residential clients including but not limited to:

  • Daily house commitment (chore)

  • Full-time employment within seven days

  • Weekly attendance at a minimum of five meetings, independent counseling and community education group

  • Sponsor involvement including working the 12 steps

  • Prompt and timely payment of all weekly program fees

  • Participation in periodic community service projects and HFT sponsored events

  • Compliance with all HFT policies and procedures (See "FAQ" page in website)

 

 Do you agree to be held accountable to these expectations?   Yes No

 

 

80. Are you willing and able to make a minimal six month commitment to residency?

Yes No

 

81. Do you have financial resources available to assist you with fees - $147 per week, and a $20 chart set-up fee = $167 plus $147 a week) until you secure employment?     Yes No

 

 

82. If no, how much do you have? 

 

 

83. Who referred you to Hope for Tomorrow, Inc.? 

 

 

84. If your referral source is not on the list above enter it here.

 

85. Have you attended any self-help groups in the last 30 days? i.e. AA, CA, NA, GA

Yes     No      Refused     Don't Know

 

85B. If yes, how many? 

86. Do you have a 12 step sponsor?     Yes     No      Temporary

 

 

87. What step are you working on?   

 

 

88. Have you ever completed a 4th and 5th step?    Yes     No      Partially

 

 

89. Have you had any interaction with family and/or friends, that are supportive or your recovery, in the last 30 days?

  Yes     No      Refused     Don't Know

 

 

When you have finished and are sure you have answered all the questions, carefully read the statement below before clicking the SUBMIT button. If you have not answered all questions "SUBMIT" button will not work and an error message will pop up.

 

By clicking the SUBMIT button below, you hereby submit this confidential intake questionnaire to Hope for Tomorrow, Inc. for the purpose of seeking admission into one of their sober residential programs. Submitting false or misleading statements and/or answers may result in not being accepted into Hope for Tomorrow, Inc's. residential program or in being discharged after initial acceptance.

 

 

 

 

IMPORTANT: You must see a "Receipt of Application Confirmation" page for application to have been submitted properly.

 


Form developed by L J Data & Web Solutions
Copyright © 2007 Hope for Tomorrow, Inc. All rights reserved.
Revised: 08/10/16
 
 
 
 
For more information, please send an email to Hope For Tomorrow
Licensed and funded in part by the Illinois Department of Human Services,
Division of Alcoholism & Substance Abuse (DASA)
Member of the Illinois Association of Extended Care (IAEC)