Residential Application - The Transition House

+1 (407)-892-5700 info@transitionhouse.org

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Application for Residential Admissions

Date

Name *

First

Middle

Last

SSN *

Date of Birth *

Gender *

Referral Agency

Agency Name *

Agency Address *

Address Line 1

Address Line 2

City

State

Zip Code

Referring Person *

First

Last

Agency Phone Number *

Drug History

Have you been a client with TTHI before *

Yes
No

If yes, where?

If yes, date?

Have you been to other treatment facilities? *

Yes
No

Primary Drug of Choice: *

Age of First Use: *

Frequency of Use: *

Daily
Weekly
Monthly
Etc.

Secondary Drug of Choice:

Age of First Use:

Frequency of Use:

Daily
Weekly
Monthly
Etc.

Third Drug of Choice:

Age of First Use:

Frequency of Use:

Daily
Weekly
Monthly
Etc.

Medical Insurance

Do You Have Insurance? *

Yes
No

Company: *

Policy *

Policy Holder's Name: *

Type of Coverage

PPO
HMO
Other

If other, what type?

Medical History

When was your last TB test?

If it was within 12 months of your release date, please email us a copy or bring it with you upon admission

Do you have any present medical conditions? *

Yes
No

Do you have any past medical conditions? *

Yes
No

If yes, please list: *

Are you able to climb a short ladder to a top bunk bed? *

Yes
No

Are you able to walk up and down stairs? *

Yes
No

Do you have a pet allergy to dogs? *

Yes
No

The Transition House at 3800 5th Street, St. Cloud utilizes a service dog on site.

Psychiatric History

Do you have a past or present psychiatric diagnosis? *

Yes
No

If yes, what was the diagnosis? *

When were you diagnosed?

Medication

Are you currently taking any medication? *

Yes
No

If yes, please list medications *

Military History

Are you a veteran? *

Yes
No

If yes, what branch did you serve in? *

Enrollment Date *

Discharge Date *

Type of Discharge *

Income Status

Last Place of Employment *

Dates employed: Start Date

End Date

What kind of work experience do you have?

Income Status

Are you currently employed? *

Yes
No

Where are you employed? *

Do you receive other income? *

Yes
No

If yes, what kind?

SSI
SSDI
Unemployment
Child Support
Pension
Other

Click all that apply

Monthly Income: *

Do you have any financial responsiblites? *

Yes
No

If yes, what kind? *

Legal History

Do you have any legal issues? *

Yes
No

If yes, please list *

Please list charge, dates, locations

Have you been in prison? *

Yes
No

If yes, please list WHEN and WHERE *

Release Date(s) *

Release Date(s) *

Are you currently on probation, parole, or community service?

Yes
No

If yes, explain *

Probation Officer's Name

First

Last

Probation Officer's Address

Address Line 1

Address Line 2

City

State

Zip Code

Probation Officer's Phone Number

Education

Do you have your GED? *

Yes
No

Highest grade completed

Do you have a college degree? What was your field of study?

Marital Status

Marital Status *

Single
Married
Divorced
Separated

Do you have children? *

Yes
No

If yes, please list how many and their ages *

Do you have parental rights? *

Yes
No

Whom do your children reside with? *

Where do they reside? *

Is your family supportive of you seeking help for your substance use disorder? *

Yes
No

Please Explain *

Living Arrangements

Are you homeless? *

Yes
No

How many times have you been homeless? *

1-5
5-10
10+

How long were you homeless? *

During your periods of homelessness

What is your current address?

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number (cell)

Emergency Contact

Name *

First

Last

Phone Number *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Relationship *

Your Goals & Plans

What do you hope to accomplish if you are admitted? *

What are your short-term goals? *

What are your long-term goals? *

What is your plan to obtain employment? *

Do you have a resume? *

Yes
No

What are your plans to obtain long-term permanent housing? *

How will you provide required documentations? *

Submitted with application
Bring upon admission

File Upload *

Click or drag files to this area to upload. You can upload up to 8 files.

Items to be included with your application or to bring upon admission into The Transition House - (Must be submitted within 1 month of admission) *History&Physical, All Lab Work, MARS, TB/PPD Results, BIO/Psycho/Social. Nursing Assessment, 30 days of medication. STD testing

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At The Transition House, we provide our residents with valuable resources and support to help them rise up and become positive contributors to their community. Our supportive environment supplies each person we serve with the knowledge they need to make healthy decisions, set productive boundaries, manage substance use/mental health needs – all while helping secure financially beneficial employment.

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Contact Info

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+1 (407)-892-5700

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info@transitionhouse.org

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3800 5th Street, St.Cloud, FL 34769