Habilitat Admission Application

*Completing our application does not mean the applicant is accepted nor does it guarantee their acceptance.
* If the applicant is dishonest, ommits information or provides inaccurate information, the application can be
immediately terminated at Habilitat’s discretion.

Print Application

*Home Phone:
Cell Phone:
*Height:
*Weight:
*Nationality:
*Gender:

*Your email

Place of Birth

Home Address
*Street Name:

Mailing Address
Same as home address
Street Name:

Identification

Please check the following you possess:

*Birth Certificate: YesNo
*Where is it:
*Social Security Card: YesNo
*Where is it:

*Does the name on your Birth Certificate match the name on your other ID's? YesNo

Emergency Contact

*Full Name:
*Relation to You:
*Home Phone:
Cell Phone:

Address:

*How did you hear about Habilitat?

*Why do you want to come to Habilitat? (be specific)
*Marital Status: SingleMarriedLegally DivorcedLegally SeparatedIn a relationship

Partner Info

Full Name:
Phone:

Address:

*Do you have children? YesNo

If yes, please state names, ages, where and who they are living with for each child below:

*Do you have siblings? YesNo

If yes, please state names, ages, where and who they are living with for each sibling below:

Parent Information

*Biological Father AliveDeceased
*Full Name:
Address:

*Biological Mother AliveDeceased
*Full Name:
Address:

Please explain the relationship you have with your family (close, distant, broken, non-existent)

Legal Situation

What were you most recently arrested for?

Are you currently in custody? YesNo

If so, what is the name of the facility?

When is you next court date?
What is the court date for?

*Are you currently on probation? YesNo

If yes,

*Are you a repeat offender? YesNo
*Have you ever been convicted of a sexual offense? YesNo
*Do you have any warrants? YesNo
If yes, what for and from what state?
*Have you ever been convicted of a violent crime? YesNo
If yes, please explain:
*Are you pursuing any lawsuits? YesNo
If yes, describe the reason:
*Are you a defendant or witness to a pending case? YesNo
If yes, please explain:
How much Prison/Jail time have you served in your life?

Disability Benefits

*Are you currently receiving benefits from the state? YesNo
If yes, Check which benefits you are receiving (check all that apply)
Food StampsMedical InsuranceFinancial

Start Date of your benefits:
End Date of your benefits:

Office location you applied for benefits at:
*Have you ever been denied benefits from the state? YesNo
If yes, why were you denied?
Where is you EBT card and medical card?
*Are you currently receiving Social Security Disability Benefits? YesNo
If yes, what is the disability you receive benefits for?
How long have you had this disability?
Is there a beneficiary to the account other than yourself? YesNo
How much do you receive per month?
Where is your medicare card?
Check if you receive: UnemploymentTemporary Disability Income (TDI)

Financial

*Do you have a bank account?

Type of account:
Balance:
Is it a joint account?
Who is the joint account holder?
Do you have any of the following? (select all that apply) Trust FundStocks/Bonds/401kLife InsuranceBurial Insurance
If yes, please list the value and description of each below:
Do you own a car? YesNo

Value:
Name on title?
Are there payments due? YesNo

Liabilities

Addiction Treatment History

Please list the names, length of stay and whether or not you completed treatment centers you've entered in the past:

Have you ever been a resident at Habilitat? YesNo
Have you applied to Habilitat in the past? YesNo

Please list your drug(s) of choice, the age you started and the date last used:

Please list substances you are currently taking on a daily basis and include dosage:

Educational Background

Highest grade completed:
Name of school:

Do you have a: GEDHigh School Diploma
Did you attend college? YesNo
Name of college:
Did you graduate? YesNo
Type of degree:

Employment History

Please list your employment history, include company name, job description and length of employment:

If you are self employed, do you file General Excise Tax? YesNo
Were you ever in the Military? YesNo
If so, list your start and end date:
Status of discharge:
Do you receive V.A. coverage or benefits? YesNo
If so, please list amount:

Insurance

Do you have medical insurance? YesNo
If so, what type?

Is the plan through your employer? YesNo
If yes, please list your employer's name, address and phone number:
Do you have any pending insurance settlements? YesNo

Psychological

Have you ever been admitted into a psychiatric hospital/mental institution? YesNo
If yes, please list the date of admission, reason for admission and length of stay for each:

Have you ever been diagnosed with any of the following:

Have you ever been treated by a Psychiatrist/Psychologist? YesNo
If yes, please list the Dr. name, state, dates and reason you were treated?

Are you currently taking any psychotropic medication? (Antidepressants, Anti-Anxiety, Anti-Psychotics, Mood Stabilizers, etc,)
YesNo
If yes, please list the name of medication, the purpose and length of time you have been taking for all:

Have you ever attempted suicide? YesNo
If yes, please list the date, reason and method for each attempt:

Medical

*Musculoskeletal/Activity/ Mobility

No ProblemsMuscle or Joint PainJoint RednessBack PainNumbness/ TinglingArthritisOsteoporosisRheumatic FeverActivity RestrictionsStiffness Redness or Swelling in Joints

Describe past or present injuries or surgeries:

*Skin Integrity

No ProblemsOpen areas/sores on bodyDrynessPsoriasisRashesEczemaLesions/Lumps

Describe any skin problems:

*Respiratory (Breathing)

No ProblemsHistory of TB or respiratory infectionsChest pain with breathingShortness of BreathEmphysemaSleep ApneaConstant cough/ Coughing up bloodAsthmaNight Sweats

*EENT(Ears, Eyes, Nose & Throat)

NormalHard of hearingWear glasses or contactsBlindnessGlaucomaTracheotomyCleft lip or palateGlassesAllergies (Hay Fever, etc.)

Describe any other problems:

*Cardiovascular (Heart)

NormalChest pain/discomfortSwelling of feetDifficulty breathing with activityDifficulty breathing lying downDizzinessHistory of high blood pressureHeart Pounding Racing or Irregular Beats

Describe any other problems:

*Gastrointestinal (Mouth, Stomach and Bowels)

NormalStomach pain associated with eatingNauseaHeartburnVomitingSwallowing DifficultiesMouth lesionsAnorexia/ BulimiaProblems with bowel eliminationAbdominal painLiver/ Gallbladder problemsBlood in stoolDiarrheaDental problems

Describe any other problems:

*Genitourinary (Urinating and Genitals)

NormalPainful urinationBlood in urineFrequent urinationProstate problemsBladder problemsIncontinenceDischarge from genitalsChlamydiaGonorrheaSyphilisHerpesGenital Warts

Describe any other problems:

*Neurological

NormalRemembering thingsSeizuresTwitchingSpeech problemsMuscle WeaknessParalysisFrequent headachesTremorFaintingNumbness

Describe any other problems:

*Psychiatric

NormalMood swingsObsessive thoughtsHearing voicesCompulsive actsDifficulty focusing

Describe any other problems:

*Endocrine

NormalDiabetesRecent weight loss or gainThyroid problemsPituitary problems

Describe any other problems:

*Hematological (BLOOD)

NormalAbnormal blood testsCancerHIV positiveBlood transfusionsHepatitis positive (A, B, C, D)

Describe any other problems:

*Sexual Preference:
Heterosexual (Straight)BisexualHomosexual (Gay)

Describe any other problems:
General

*Name and contact info for who will be responsible for medical bills/copayments (if any):

*Do you have any allergies? YesNo
Please list all allergies:

WOMEN ONLY

Last menstrual period:
Last Pap Smear or GYN Visit:

Breast LumpsIrregular bleeding or dischargePossibility of pregnancy

* I certify that I have answered all questions honestly to the best of my ability