Application for Residential Admissions Please enable JavaScript in your browser to complete this form.Date Name *FirstMiddleLastSSN *Date of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender *MaleFemaleTransgenderReferral AgencyAgency Name *Agency Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeReferring Person *FirstLastAgency Phone Number *Drug HistoryHave you been a client with TTHI before *YesNoIf yes, where? If yes, date? Have you been to other treatment facilities? *YesNoPrimary Drug of Choice: *Age of First Use: *Frequency of Use: *DailyWeeklyMonthlyEtc.Secondary Drug of Choice: Age of First Use: Frequency of Use: DailyWeeklyMonthlyEtc.Third Drug of Choice: Age of First Use: Frequency of Use: DailyWeeklyMonthlyEtc.Medical InsuranceDo You Have Insurance? *YesNoCompany: *Policy *Policy Holder's Name: *Type of Coverage PPOHMOOtherIf other, what type?Medical HistoryWhen 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 admissionDo you have any present medical conditions? *YesNoDo you have any past medical conditions? *YesNoIf yes, please list: *Are you able to climb a short ladder to a top bunk bed? *YesNoAre you able to walk up and down stairs? *YesNoDo you have a pet allergy to dogs? *YesNoThe 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? *YesNoIf yes, what was the diagnosis? *When were you diagnosed? MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920MedicationAre you currently taking any medication? *YesNoIf yes, please list medications *Military HistoryAre you a veteran? *YesNoIf yes, what branch did you serve in? *Enrollment Date *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Discharge Date *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Type of Discharge *Income Status Last Place of Employment *Dates employed: Start Date MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920End Date MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What kind of work experience do you have?Income Status Are you currently employed? *YesNoWhere are you employed? *Do you receive other income? *YesNoIf yes, what kind?SSISSDIUnemploymentChild SupportPensionOtherClick all that apply Monthly Income: *Do you have any financial responsiblites? *YesNoIf yes, what kind? *Legal HistoryDo you have any legal issues? *YesNoIf yes, please list *Please list charge, dates, locations Have you been in prison? *YesNoIf yes, please list WHEN and WHERE *Release Date(s) *Release Date(s) *Are you currently on probation, parole, or community service?YesNoIf yes, explain *Probation Officer's Name FirstLastProbation Officer's AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeProbation Officer's Phone NumberEducationDo you have your GED? *YesNoHighest grade completedDo you have a college degree? What was your field of study?Marital Status Marital Status *SingleMarriedDivorcedSeparatedDo you have children? *YesNoIf yes, please list how many and their ages *Do you have parental rights? *YesNoWhom do your children reside with? *Where do they reside? *Is your family supportive of you seeking help for your substance use disorder? *YesNoPlease Explain *Living Arrangements Are you homeless? *YesNoHow many times have you been homeless? *1-55-1010+How long were you homeless? *During your periods of homelessness What is your current address?Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone Number (cell)Emergency ContactName *FirstLastPhone Number *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeRelationship *Your Goals & PlansWhat 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? *YesNoWhat are your plans to obtain long-term permanent housing? *How will you provide required documentations? *Submitted with applicationBring upon admissionFile 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 testingSubmitSave and Resume Later Your form entry has been saved and a unique link has been created which you can access to resume this form. Enter your email address to receive the link via email. Alternatively, you can copy and save the link below. Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted. Copy Link Email * Send Link
