AMETHYST HOUSE
APPLICATION - FOR RESIDENCY
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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: |
_______________________ |
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| Why do you want to live at Amethyst?: |
___________________ |
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| DRUG(S) of CHOICE |
First use |
Last use |
How did you begin using? |
| 1 |
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| 2 |
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| 3 |
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| 4 |
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| Have you ever used needles? |
_______________________________ |
| Have you ever shared needles? |
_______________________________ |
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Other Addictive Patterns:
(check all that apply) |
___ |
food |
___ |
weight |
___ |
sex |
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___ |
gambling
(including lottery) |
___ |
work |
___ |
other |
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| Current Legal Status: |
______________________________________ |
| Last offense: |
______________________________________ |
| Pending charges: |
______________________________________ |
| Court dates: |
______________________________________ |
| Probation officer: |
______________________________________ |
| County: |
______________________________________ |
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| Financial Status: |
______________________________________ |
| Employment: |
______________________________________ |
| How long? |
______________________________________ |
| Other income: |
______________________________________ |
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| Do you have insurance? |
________ |
Medicaid? |
_____ | Medicare? |
_____ |
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| Medical/Physical Status: |
| __________________________________________________________ |
| Current medical problems or needs: |
| __________________________________________________________ |
| Allergies: |
| __________________________________________________________ |
| Medications, and what it is for: |
| __________________________________________________________ |
| Health care provider: |
| __________________________________________________________ |
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| Prior Treatments (List all substance abuse treatments, and dates) |
| __________________________________________________________ |
| __________________________________________________________ |
| __________________________________________________________ |
| __________________________________________________________ |
| __________________________________________________________ |
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| List any other mental health treatment or counseling (include where and dates): |
| __________________________________________________________ |
| __________________________________________________________ |
| __________________________________________________________ |
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| Describe your experience with 12-step programs: |
| __________________________________________________________ |
| __________________________________________________________ |
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| Do you go to meetings now? |
_____ |
Why? |
________________________ |
| If yes, how many a week? |
____________________________________ |
| Do you have a sponsor? |
_____ |
Why? |
____________________________ |
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| 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? |
______________ |
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| Who supports you in your recovery efforts now? | ______________ |
| Relationship to you: |
|
| __________________________________________________________ |
| __________________________________________________________ |
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| Do you have any other problems or concerns in your life right now? (Describe) |
| __________________________________________________________ |
| __________________________________________________________ |
| __________________________________________________________ |
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| Dependent children: Name |
age |
where are they living? |
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| Do you plan to make an application to Amethyst for your child(ren)? |
_____ |
| Explain: |
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| __________________________________________________________ |
| __________________________________________________________ |
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| Do you pay child support?
| ______________ |
County: |
______________ |
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| Amount: __________________ |
| How much back child support do you owe?_____________________ |
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| FOR WOMEN: Are you currently pregnant? _________ |
| Prenatal care: _______________________________________________ |
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| 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. |
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| _____ |
I have read the community agreements and understand them. |
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| Applicant's signature: ________________________ |
Date: ________ |
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| Mail, Fax or Deliver completed application to: |
Amethyst Administrative Office, P.O. Box 11 |
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[645 N. College- corner of 11th and Walnut] |
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Bloomington, IN 47402 |
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Phone: 812 336-3570 |
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Fax: 812 336-9010 |
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OR drop off at the halfway house |
