HERO Juvenile Program Application
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- Piers Peters
- 5 years ago
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1 page 1 of 10 HERO Juvenile Program Application Date Level of Care Applying for: Non-Residential Outpatient (2 nights/week) Non-Residential Intensive Outpatient (4 nights/wk) Evaluation, Only A. Demographic Data Date of Interview: Name: Gender: DOB: Age: SSN: Language(s) Spoken: Race: Religious Preference: Culture/Ethnicity: Current Telephone Number: Current Address Street Length of time there Parent/Legal Guardian (Emergency Contact) Name Relationship Street Telephone 1 (home) Telephone 2 (cell) Telephone 3 (work) Do you have a valid ID? Y N Do you have a car available for your use? Y N Do you have a valid Driver s License? Do you have a copy of your Social Security card? B. Financial (Self) Source Amount Caseworker/Telephone # 1. Source of income 2. Medical Health Insurance Coverage (Photo copy card and attach)
2 page 2 of Agencies currently providing services to me: (example: Community Alliance, Friendship Program, et) C. Financial (Parent/Guardian) Source Amount Caseworker/Telephone # 1. ADC 2.General Assistance 3. SSI 4. Unemployment 5. Disability 6. Medicare 7. Medicaid 8. Social Security 9. Pension or retirement 10. Veterans Benefits 11. Family Support 12. Other sources of income 13. Social Services you may need: (examples: job services, ex-felon services, health care, dental care, legal services, education, et) D. Medical History 1. Current Medications Dosage, Description, Prescribing Physician 2. Are you currently taking medications listed above and only as directed? 3. Allergies? (Please list) Yes No 4. Physical/Medical Concerns 5. Physical Problems in last three months 6. Family history of: If yes, please explain:
3 page 3 of 10 Cancer: Diabetes: Stroke: High Blood Pressure: Heart attack before age 50: Asthma: Emphysema: 7. Women Only: How many pregnancies have you had? Date of last female exam: Date of last mammogram: What method of birth control are you using, if any? Are you pregnant? 8. Men & Women: Do you need to be tested for or have you been Are you sexually active? diagnosed with HIV? Do you have symptoms of or are If yes, please explain: receiving treatment for an STD? Do you want to be tested for an STD? 9. Health Behaviors: # of cigarettes smoked per day: # of days per week exercise: Healthy eating habits? 10. Immunizations: Have you had: TB Skin test? Tetanus shot within the last 10 years? Reaction? Flu shot this year? Hepatitis B series of shots? Are immunization records up to date? 11. Are you currently receiving medical treatment? Condition Physician and contact information 12. Is there any medical condition you should be receiving treatment for or you would like to discuss with a nurse or medical practitioner? If so, please describe: 13. Do you have any chronic conditions? e.g. diabetes, epilepsy, high blood pressure, HIV infection not disclosed in #8 above?
4 page 4 of 10 E. Vocational History 1. Level of education 2. Did you complete high If you did not complete high school, explain why. school? 3. Previous jobs: 4. Type/Name of Company Dates Reason for leaving Salary F. Legal History 1. Legal Guardian Information Name Mailing Address Telephone contact 2. Probation/Parole Officer/Case Worker Name Mailing Address Telephone contact 3. Attorney Name Mailing Address Telephone contact (List name, phone number and full address) (List name, phone number and full address) (List name, phone number and full address) 4. Legal Charges -- be specific Current Charges Past Convictions
5 page 5 of 10 G. Chemical Dependency/Substance Abuse History 1. Have you had a substance abuse evaluation within the past 6 months? If so, what is the name of the counselor and/or treatment center that completed the evaluation? 2. Have you been through treatment for chemical dependency or substance abuse? Treatment facility and year Did you complete treatment successfully? If no, why not? What substances have your parent/guardian used? 3. What substances have you used? ( ) Alcohol ( ) Amylnitrates (poppers, rush, locker room) ( ) Amphetamines (uppers, crystal, meth, speed, speedball, ice, crank, dexedrine, Ritalin, black beauties) ( ) Anabolic steroids (roids, juice) ( ) Chewing tobacco (snuff) ( ) Cocaine ( ) Codeine products (codeine, Percodan) ( ) Cough syrup ( ) Diet pills (prescription: preludin, tenuate, tepanil, Sanorex) ( ) Diet pills (over the counter: Dexatrim, Acutrim, Ephedrine HCL, caffeine) ( ) Downers (Xanax, Ativan, Librium, Quaaludes, seconal, valium, halcyon, dalmane, serex) ( ) Ectasy (MDMA, MDA) ( ) Heroin (smack, horse, synthetic china white, T s blues) ( ) K2 Bath (Please check all that you have tried) (china white, T s, blues) ( ) K2, Bath Salts ( ) Inhalants (white out, paint, huff, oz) ( ) Ketamines (cat killer, honey oil, jet) ( ) LSD (acid, trip, paper) ( ) Marijuana (hashish, pot, reefer, green, bud, ditch weed, weed) ( ) Methadone ( ) Morphine ( ) No Doz ( ) Nitrous Oxide ( ) Nyquil ( ) Opium ( ) Pain Killers: Prescription (Darvon, Dilaudid, Demerol, Percocet, Percodan, Oxycontin, Hydrocodone) ( ) Peyote (buttons, mescaline) ( ) Phencyclidine (PCP, angel dust, peace pill, hog, tic, zoot) ( ) Psilocybin (mushrooms) ( ) Tobacco: Chewing (snuff) ( ) Tobacco: Smoking (cigarettes, pipe, cigars) ( ) Other:
6 page 6 of 10 H. Detailed Substance Use History (Required for Consideration) Of those substances checked in H, answer these questions: Substance Age of First Use Date of Last Use Amount Of Last Use Amount Generally Used in 24 hr. Period Worst Experience From Use Do you have any other compulsive behaviors such as gambling, over spending, sexual acting out? If yes, have you ever received counseling for any compulsive behavior? If so, please explain. I. Family Situation 1. Parents/Guardian Marital status circle one 2. Parents/Guardian contact information (if applicable) Name Address Telephone 1 Telephone 2 Married Single Separated Divorced Widowed 3. Number of siblings Self-Marital status-circle one Married Divorced Single Widowed Separated 4. Number of biological children
7 page 7 of Children Name Age Sex d. Biological mother/father 6. Child Support Information (Include amount you are ordered to pay, if any, and amount you are able to pay, if any, as well as any past due amounts) 7. What do you find difficult about ( ) Discipline parenting? ( ) Nurturing ( ) Communication ( ) Meeting basic needs ( ) What to expect ( ) Choice of Friends ( ) Other 8. Have any of your children been removed from your custody? Explain. 9. Who lived in your family when you were growing up? 10. As a child, were you in foster care or another type of out of home placement? Explain. 11. Has anyone in your family had a mental illness or an addiction? Explain 12. Is there anything else you would like to tell us about your family? 13. Do you have any connection with any current resident or staff member of Stephen Center HERO Program? (Include using friends, current or past relationships, relatives, co-defendants, et) Explain:
8 page 8 of 10 J. Abuse History 1. Physical Have you ever been the victim of physical abuse? Have you ever been the perpetrator of physical abuse? 2. Sexual Have you ever been the victim of sexual abuse? Have you ever been the perpetrator of sexual abuse? 3. Emotional Have you ever been the victim of emotional abuse? Have you ever been the perpetrator of emotional abuse? 4. Have you ever abused animals? K. Emotional/Mental History and Current Situation Assessment 1. Diagnosis and year of treatment for mental or emotional problems. Please be specifi Diagnosis and year Diagnosis and year Diagnosis and year Were you treated as an outpatient or in a hospital?
9 page 9 of What three things worry you the most right now? 3. What events have you experienced in the last 12 months? 4. What do you feel now or have felt in the last three months? ( ) Death of spouse ( ) Death of someone else in immediate family: Specify: ( ) Death of a close relative other than these. Specify: ( ) Death of a friend ( ) Marital separation ( ) Divorce ( ) Loss of close/intimate relationship ( ) Loss of contact with friends/family ( ) Birth of child ( ) Marriage ( ) Change in financial status ( ) Fired from work ( ) Quit work ( ) Change in living conditions ( ) Trouble with boss ( ) Violations of law ( ) Personal illness or injury ( ) Jail Term ( ) Other ( ) Nightmares ( ) Helpless ( ) Poor self image ( ) Low self-esteem ( ) Puzzling ideas ( ) Panicky ( ) Do not care ( ) Stressed out ( ) Fearful ( ) Hopeless ( ) Suicidal thoughts ( ) Given up ( ) Irritable ( ) Depressed ( ) Angry
10 page 10 of 10 ( ) Racing thoughts ( ) Hearing voices ( ) Cannot sit still ( ) Cannot concentrate ( ) Seeing things which are not there ( ) Nervous ( ) Withdrawn ( ) Other 5. What are your best qualities? d. 6. If you could make any changes in your life, what would you change? Client Signature: Parent/Guardian: Reviewed by:
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