Admission Application Get StartedFill out your admission application online by completing the online form below, or click to download a PDF. Apply OnlineAdmission ApplicationName(Required) First Middle/Maiden Last Email Date of Interview(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date Admitted(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Referred By(Required) First Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County(Required)Zip Code of Last Permanent Address(Required)Social HistoryAgeRaceDate of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Mother's Name (Married & Maiden) First Middle/Maiden Last Father's Name First Middle Last Prior Admission to Hope Haven?(Required) Yes NoDate Last Discharged(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Last School Grade Completed(Required)Did you like school?(Required) Yes NoWhy or Why Not?(Required)Are you presently enrolled in school?(Required) Yes NoIf so, where?(Required)Are you currently on State or Federal probation?(Required) Yes NoFor what charges?(Required)PO Name(Required) First Last PO Phone Number(Required)Do we have your criminal background report?(Required) Yes NoEmployment HistoryTypes and Skills(Required)Occupation(Required)Last Employer(Required)Is this your current employer?(Required) Yes NoVR involvement?(Required) Yes NoDid you serve in the military?(Required) Yes NoBranches/Dates(Required)Did you like your stay in the military?(Required) Yes NoWhy or Why Not?(Required)What was your discharge status?(Required)Discharge DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Income InformationAny source or type of income?(Required) Yes NoAmount of Income(Required)If yes, what type of income?(Required) Pension/Retirement SSI/SSDI TANF Unemployment VA Benefits OtherAre you in the process of filing disability?(Required) Yes NoIf so, what is your status?(Required) Awaiting Hearing Denied Income PendingDo you receive Medicaid?(Required) Yes NoMedicaid Number(Required)Do you receive Medicare?(Required) Yes NoMedicare Number(Required)History of Addiction/AlcoholismDo you have a history of the following (select all that apply) Blackouts DTs Epilepsy Neuritis HallucinationsDate of Last Drink/Use(Required) MM slash DD slash YYYY Age of First Drink/Use(Required)At what age did alcohol/drugs become a problem?(Required)Alcohol/drug related arrests?(Required) Yes NoIf yes, please explain(Required)Other arrests?(Required) Yes NoIf yes, please explain(Required)Previous Treatments (List where and when)(Required)Longest Clean Time(Required)Sponsor?(Required) Yes NoPsychological HistoryHave you ever been a patient in a mental hospital?(Required) Yes NoIf yes, explain with date(s)(Required)Have you ever had a mental health assessment/evaluation?(Required) Yes NoIf yes, explain with date(s)(Required)Have you had any of the following in the last two months? Financial Burdens Lack of Sexual Desire Irritability Family Problems Weight Loss Staring Spells Problems with Job Employment Separation/DivorceHas there been abuse in your marriage or intimate relationships?(Required) Yes NoHow well do/did you get along with your significant other/spouse?(Required)NumberHow well do/did you get along with your child(ren)?(Required)Living arrangements prior to treatment?(Required)Number in HouseholdDo you ever feel afraid of your partner?(Required) Yes NoIn what ways?(Required)Has there ever been any violence in your intimate relationships? (Example: pushing, pulling, slapping, punching or kicking)(Required) Yes NoHow long ago did the most recent violence occur?(Required)Has there ever been fighting in your intimate relationships that led to damage or destruction of personal belongings, property, or pets?(Required) Yes NoHave there ever been threats to use weapons such as a gun, knives by you or your partner?(Required) Yes NoHave you ever had a partner force you to have sex against your will?(Required) Yes NoHas physical abuse ever occurred while you were high?(Required) Yes NoHas physical abuse ever occurred while your partner was high?(Required) Yes NoHave you ever gotten high to cope with the violence in your relationships?(Required) Yes NoHave the police ever been called to your home due to fighting?(Required) Yes NoMedical HistoryFamily Doctor First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of last physical examination?(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date of last TB Test:(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Result(Required) Positive NegativeDo you have a history of Diabetes Epilepsy High Blood Pressure Cancer Nervous/Mental Disorder OtherIf other, explain(Required)What over the counter medications have you taken in the last 6 months?(Required)What medications are you allergic or sensitive to?(Required)Are you currently on medication(s)?(Required) Yes NoIf yes, name(s) of medication(Required)Prescribed by(Required) First Last Do you presently have a disability that is covered under the Americans with Disabilities Act (ADA) that will require special accommodations or specific needs?(Required) Yes NoIf yes, then what is that disability and what specific accommodations or specific need will need to be made?(Required)Level of Functioning(Required)Specific Needs(Required)Females OnlyIf you are not female, please skip to the next section.Are you pregnant now?(Required) Yes No# of times pregnant(Required)Last menstrual period date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Flow Light Heavy Abnormal DischargeLast pap smear dateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920ResultsBreast Exam Pain Lump DischargeEmergency Contact InformationName(Required) First Last Phone(Required)Relationship(Required)Complete Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code ConsentPlease read and agree to the followingAs a resident of Hope Haven, I understand and accept my written responsibilities. In consideration of your admitting me as a resident to Hope Haven, I, for myself, my heirs, assigns or personal representatives, do hereby release you and your staff from any liability for any personal injury or property damage that I may sustain at any time at Hope haven, or on its premises or while I am a passenger in any vehicle, and further agree to hold Hope Haven, Inc. free and harmless from any and all liability in connection therewith: I agreeResident Signature(Required)Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920