We do not discriminate on the basis of age, race, creed, ethnicity, religion,
marital status, or sexual orientation.
| Date of Application: | _________________________________________ | |
| Name: | _________________________________________ | |
| Date of Birth: | _________________________________________ | |
| Address: | _________________________________________ | |
| __________________________________________________________ | ||
| City: | _______________________ | County: | ___________________ |
| State: | _______________________ | Zip: | ___________________ |
| Phone: | _______________________ |
| Why do you want to live at Amethyst?: | ___________________ |
| DRUG(S) of CHOICE | First use | Last use | How did you begin using? |
|---|---|---|---|
| 1 | |||
| 2 | |||
| 3 | |||
| 4 |
| Have you ever used needles? | _______________________________ |
| Have you ever shared needles? | _______________________________ |
| Other Addictive Patterns: (check all that apply) |
___ | food | ___ | weight | ___ | sex |
| ___ | gambling (including lottery) |
___ | work | ___ | other | |
| Current Legal Status: | ______________________________________ |
| Last offense: | ______________________________________ |
| Pending charges: | ______________________________________ |
| Court dates: | ______________________________________ |
| Probation officer: | ______________________________________ |
| County: | ______________________________________ |
| Financial Status: | ______________________________________ |
| Employment: | ______________________________________ |
| How long? | ______________________________________ |
| Other income: | ______________________________________ |
| Do you have insurance? | ________ | Medicaid? | _____ | Medicare? | _____ |
| Medical/Physical Status: |
| __________________________________________________________ |
| Current medical problems or needs: |
| __________________________________________________________ |
| Allergies: |
| __________________________________________________________ |
| Medications, and what it is for: |
| __________________________________________________________ |
| Health care provider: |
| __________________________________________________________ |
| Prior Treatments (List all substance abuse treatments, and dates) |
| __________________________________________________________ |
| __________________________________________________________ |
| __________________________________________________________ |
| __________________________________________________________ |
| __________________________________________________________ |
| List any other mental health treatment or counseling (include where and dates): |
| __________________________________________________________ |
| __________________________________________________________ |
| __________________________________________________________ |
| Describe your experience with 12-step programs: |
| __________________________________________________________ |
| __________________________________________________________ |
| Do you go to meetings now? | _____ | Why? | ________________________ |
| If yes, how many a week? | ____________________________________ |
| Do you have a sponsor? | _____ | Why? | ____________________________ |
| Do you have a valid driver's license? | ______________ |
| Do you own a vehicle? | ______________ |
| Do you plan to have the vehicle at Amethyst? | ______________ |
| Make & year | ______________ |
| Can you provide proof of vehicle insurance? | ______________ |
| Who supports you in your recovery efforts now? | ______________ |
| Relationship to you: | |
| __________________________________________________________ | |
| __________________________________________________________ | |
| Do you have any other problems or concerns in your life right now? (Describe) |
| __________________________________________________________ |
| __________________________________________________________ |
| __________________________________________________________ |
| Dependent children: Name | age | where are they living? |
| Do you plan to make an application to Amethyst for your child(ren)? | _____ | ||
| Explain: | |||
| __________________________________________________________ | |||
| __________________________________________________________ | |||
| Do you pay child support? | ______________ | County: | ______________ |
| Amount: __________________ |
| How much back child support do you owe?_____________________ |
| FOR WOMEN: Are you currently pregnant? _________ |
| Prenatal care: _______________________________________________ |
| I have completed this application honestly and to the best of my ability.
I understand that if I am admitted to the Amethyst House, I need to have one month's supply of any prescription medications that I am taking, as well as a pharmacy label on each prescription container. |
| _____ | I have read the community agreements and understand them. |
| Applicant's signature: ________________________ | Date: ________ |
| Mail, Fax or Deliver completed application to: | Amethyst Administrative Office, P.O. Box 11 |
| [645 N. College- corner of 11th and Walnut] | |
| Bloomington, IN 47402 | |
| Phone: 812 336-3570 | |
| Fax: 812 336-9010 | |
| OR drop off at the halfway house |