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)	Kane Dupage Will Cook Kendall Grundy LaSalle Lake McHenry Other
Cell Phone	1234567890 Numbers Only No Dashes
Home Phone	1234567890 Numbers Only No Dashes
E-mail

1. Race.  Select Here American Indian Alaskan Native Asian Native Hawaiian or other Pacific Islander Black or African American White Other Single Race

  1B. Ethnicity.    Select Here Puerto Rican Mexican Cuban Other Specific Hispanic Not of Hispanic Origin Hispanic - Specific Origin Not Specified

1C. Primary Language.    Select Here English Arabic Chinese French German Hindu Korean Polish Russian Spanish Urdu Vietnamese Other - Asian Other - African Other Indian Other

 

2. Select the one that best describes your religion:  Select here None Adventist Baptist Catholic Christian Jewish Lutheran Mormon Muslim Other

3. Drivers License or State ID Number.  Must Have Number

4. Is drivers license valid?   Yes No

5. Marital status:  Select here Never Married Married Widowed Divorced Separated

6. Number of dependants, including yourself?                                                         Select Here 1 2 3 4 5 6 7 8 9 10 11 12

 

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?   Select here Heterosexual (Straight) Gay / Lesbian Bisexual Refuse to answer

8. Are you interested in family counseling ?    Yes No

9. Veteran status:  Select here I am not a veteran of the armed services Air Force Army veteran Coast guard veteran Marine veteran National guard veteran Navy veteran

10. Last zip code you resided in? 

11. Last town you resided in? 

12. Last county (not country) you resided in?                                      Kane Dupage Will Cook Kendall Grundy LaSalle Lake McHenry Other

13. Health insurance status:  Select here Private (Other than Blue Cross/Blue Shield or an HMO) Blue Cross/Blue Shield Medicare Medicaid Health Maintenance Organization (HMO) Other None

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

  Select here Full-time (working 35 or more hours per week; includes members in the uniformed services) Part-time (working fewer than 35 hours per week) Unemployed (looking for work in the last 30 days or on layoff from a job) Not in labor force (not looking for work in last 30 days or homemaker, student, disabled, retired or an inmate)

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

Select here Homemaker Student Retired Disabled Inmate of Institution (Jail or Prison) Other Not Applicable

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?   Select here 0-6 months 7-12 months 13 months - 2 years Over 2 years

19. Annual income (now - today, not your previous income)?  Select here Zero Less than $10,000 $10,001 - $20,000 $20,001 - $40,000 $40,001 - $60,000 Over $60,001

20. Income source?:  Select here Wages/Salary Public assistance Retirement/Pension Disability Trust fund None If you are service connected what % Select Here NA 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

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

22. Highest grade completed?  Select here Grade school GED Some high school High school graduate Some college Associates degree Bachelors degree Masters degree Doctorate

23. Are you currently a student? Yes No

24. Previous treatments attempts including detox(s)?  Select Here 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 30+ N/A                                            

25. Primary drug of choice?  Select here Not Applicable Alcohol Cocaine Crack Gambling Heroin Prescription opiates Marijuana/THC Other Hallucinogens PCP - Phencyclidine LSD Methamphetamine Other Amphetamines Barbituates Benzodiazepines Ketamine (special k) Ectasy Inhalants Tranquilizers Rohypnol Steroids Ephedrine/Pseudoephedrine

Age of first use.  

 

Date of last use? Required *If Not Applicable Use 00/00/00

 

Frequency of use - prior to treatment or current abstinence?   Select here NA Daily 1-3 times a week 3-5 times a week 1-3 times a month 3-7 times a month

 

Primary drug route of administration?   Select here Oral Smoking Inhalation Injection IV or Intramuscular Not applicable

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

26. Secondary drug of choice?  Select here Not Applicable Alcohol Cocaine Crack Gambling Heroin Prescription opiates Marijuana/THC Other Hallucinogens PCP - Phencyclidine LSD Methamphetamine Other Amphetamines Barbituates Benzodiazepines Ketamine (special k) Ectasy Inhalants Tranquilizers Rohypnol Steroids Ephedrine/Pseudoephedrine

Age of first use.

 

Date of last use? Required *If Not Applicable Use 00/00/00

 

Frequency of use - prior to treatment or current abstinence?   Select here NA Daily 1-3 times a week 3-5 times a week 1-3 times a month 3-7 times a month

 

Secondary drug route of administration?  Select here Oral Smoking Inhalation Injection IV or Intramuscular Not applicable

 

 

27. Tertiary or third drug of choice?    Select here Not Applicable Alcohol Cocaine Crack Gambling Heroin Prescription opiates Marijuana/THC Other Hallucinogens PCP - Phencyclidine LSD Methamphetamine Other Amphetamines Barbituates Benzodiazepines Ketamine (special k) Ectasy Inhalants Tranquilizers Rohypnol Steroids Ephedrine/Pseudoephedrine

Age of first use.

 

Date of last use? Required *If Not Applicable Use 00/00/00

 

Frequency of use - prior to treatment or current abstinence?   Select here NA Daily 1-3 times a week 3-5 times a week 1-3 times a month 3-7 times a month

 

Tertiary drug, route of administration?  Select here Oral Smoking Inhalation Injection IV or Intramuscular Not applicable

 

 

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.

  Select here I have no idea I stopped going to meetings and/or working the steps I started working more hours I put others needs before my own None of these look familiar. Not Applicable

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.

  Select here Shelter (Safe Havens, Transitional Living Centers, Low Demand Facilities, Reception Centers, Other Temporary Day or Evening Facilities) Street / Outdoors (Sidewalk, Doorway, Park, Public or Abandoned Building) Institution (Hospital, Nursing Home, Jail / Prison) Owned or Rented Apartment, Room, or House Someone Else's Apartment, Room or House Dormitory / College Residence Halfway House Residential Treatment Recovery Home Other Housed

 

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.
  None DuPage County PADS Hesed House Lazarus House Wayside Cross Ministries  

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)? (DO NOT INCLUDE: HOSPITALS, INCARCERATIONS, TREATMENT CENTERS, ETC.)

  Select here Less than a day Less than a week 1-2 weeks 1 month 2 months 3 months 4 months 5 months 6 months 7- 12 months 1 year 2 years 3 years 4 years 5 years or more Not Applicable

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?  Select here Stay sober Work the steps Maintain Wellness Family reunification Get a job Straighten out legal situation Financial responsibility Get a sponsor 90 meetings in 90 days Buy a car Get my drivers license back Find a girl/boy friend Get my own place Get back to church Rebuild/find spirituality (Re)build relationships

69. Number two goal for the next six months.  Select here Stay sober Work the steps Family reunification Maintain Wellness Get a job Straighten out legal situation Financial responsibility Get a sponsor 90 meetings in 90 days Buy a car Get my drivers license back Find a girl/boy friend Get my own place Get back to church Rebuild/find spirituality (Re)build relationships

70. Number three goal for the next six months.  Select here Stay sober Work the steps Family reunification Maintain Wellness Get a job Straighten out legal situation Financial responsibility Get a sponsor 90 meetings in 90 days Buy a car Get my drivers license back Find a girl/boy friend Get my own place Get back to church Rebuild/find spirituality (Re)build relationships

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?   Select here NA Aurora parole Parole - other Cook Cook county drug court Dekalb DuPage DuPage county drug court Grundy Kane Kane county drug court Kankakee Kendall Kendall county drug court Lake LaSalle Livingston McHenry Will Will county drug court

 

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 - $168 per week, and a $20 chart set-up fee = $188 plus $188 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.?  Select here Alexian Brothers Hospital BHS - Central DuPage Hospital Central DuPage Hospital Department of Corrections Edwards Hospital Good Samaritan Hospital Hinsdale Hospital Provena Mercy Hospital Hospital - Other Attorney Breaking Free Carpenters Place Community Christian Church Cornell Interventions Creative Counseling Connections Diversionary Program Employer or EAP Family Friend Gateway Ginger Creek Church Hesed House Internet Judge Keys to Recovery The Larkin Center Lazarus House New Day Center Other treatment center Parole Phone Book - (not Yellow Pages) Physician Probation Prosecutor Psychiatrist Rosecrance Serenity House Self Share South Suburban Council Stepping Stones TASC VA - Great Lakes VA - Hines VA - Iron Mountain VA - Jesse Brown VA - Milwaukee VA - Tomah VA - VISN Yellow Pages Other (See next question)

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.