Application for Residential Admissions Please enable JavaScript in your browser to complete this form.Date Name *FirstMiddleLastSSN *Date of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender *MaleFemale TransgenderReferral AgencyAgency Name *Agency Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict 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 *Yes NoIf yes, where? If yes, date? Have you been to other treatment facilities? *Yes NoPrimary 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 InsuranceDo You Have Insurance? *YesNo Company: *Policy *Policy Holder's Name: *Type of Coverage PPOHMOOther If 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? *YesNo Do you have any past medical conditions? *YesNo If yes, please list: *Are you able to climb a short ladder to a top bunk bed? *YesNo Are you able to walk up and down stairs? *YesNo Do you have a pet allergy to dogs? *YesNo 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? *YesNo If yes, what was the diagnosis? *When were you diagnosed? MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920MedicationAre you currently taking any medication? *YesNo If yes, please list medications *Military HistoryAre you a veteran? *YesNo If yes, what branch did you serve in? *Enrollment Date *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Discharge Date *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Type of Discharge *Income Status Last Place of Employment *Dates employed: Start Date MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920End Date MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What kind of work experience do you have?Income Status Are you currently employed? *Yes NoWhere are you employed? *Do you receive other income? *Yes NoIf yes, what kind?SSISSDIUnemploymentChild SupportPensionOther Click all that apply Monthly Income: *Do you have any financial responsiblites? *YesNoIf yes, what kind? *Legal HistoryDo you have any legal issues? *Yes NoIf yes, please list *Please list charge, dates, locations Have you been in prison? *Yes NoIf 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 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeProbation Officer's Phone NumberEducationDo you have your GED? *Yes NoHighest grade completedDo you have a college degree? What was your field of study?Marital Status Marital Status *SingleMarried DivorcedSeparatedDo you have children? *YesNoIf yes, please list how many and their ages *Do you have parental rights? *Yes NoWhom 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 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone Number (cell)Emergency ContactName *FirstLastPhone Number *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict 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 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 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