Apply for a Bed | Jeremiah's Inn

For a printable version of this application, please click here

For application requirements, please click here

Resident Application Form

Application form for potential residents in the social model recovery program. Rev. 10/20

Step 1 of 4

Substance Use Information (cont.)
Alcohol - Age of First Use
Alcohol - Last Use
Alcohol - Frequency
Alcohol - Usual Route
Cocaine - Age of First Use
Cocaine - Last Use
Cocaine - Frequency
Cocaine - Usual Route
Crack - Age of First Use
Crack - Last Use
Crack - Frequency
Crack - Usual Route
Marijuana/Hashish - Age of First Use
Marijuana/Hashish - Last Use
Marijuana/Hashish - Frequency
Marijuana/Hashish - Usual Route
Heroin - Age of First Use
Heroin - Last Use
Heroin - Frequency
Heroin - Usual Route
Non Rx Methadone - Age of First Use
Non Rx Methadone - Last Use
Non Rx Methadone - Frequency
Non Rx Methadone - Usual Route
Other Opiates - Age of First Use
Other Opiates - Last Use
Other Opiates - Frequency
Other Opiates - Usual Route
PCP - Age of First Use
PCP - Last Use
PCP - Frequency
PCP - Usual Route
Other Hallucinogens - Age of First Use
Other Hallucinogens - Last Use
Other Hallucinogens - Frequency
Other Hallucinogens - Usual Route
Methamphetamine - Age of First Use
Methamphetamine - Last Use
Methamphetamine - Frequency
Methamphetamine - Usual Route
Other Amphetamines - Age of First Use
Other Amphetamines - Last Use
Other Amphetamines - Frequency
Other Amphetamines - Usual Route
Other Stimulants - Age of First Use
Other Stimulants - Last Use
Other Stimulants - Frequency
Other Stimulants - Usual Route
Benzodiazepines - Age of First Use
Benzodiazepines - Last Use
Benzodiazepines - Frequency
Benzodiazepines - Usual Route
Other Tranquilizers - Age of First Use
Other Tranquilizers - Last Use
Other Tranquilizers - Frequency
Other Tranquilizers - Usual Route
Barbiturates - Age of First Use
Barbiturates - Last Use
Barbiturates - Frequency
Barbiturates - Usual Route
Other Sedatives/Hypnotics - Age of First Use
Other Sedatives/Hypnotics - Last Use
Other Sedatives/Hypnotics - Frequency
Other Sedatives/Hypnotics - Usual Route
Inhalants - Age of First Use
Inhalants - Last Use
Inhalants - Frequency
Inhalants - Usual Route
Over-the-Counter - Age of First Use
Over-the-Counter - Last Use
Over-the-Counter - Frequency
Over-the-Counter - Usual Route
Ecstasy - Age of First Use
Ecstasy - Last Use
Ecstasy - Frequency
Ecstasy - Usual Route
Nicotine - Age of First Use
Nicotine - Last Use
Nicotine - Frequency
Nicotine - Usual Route
Caffeine - Age of First Use
Caffeine - Last Use
Caffeine - Frequency
Caffeine - Usual Route
Other - Age of First Use
Other - Last Use
Other - Frequency
Other - Usual Route
Other - Age of First Use
Other - Last Use
Other - Frequency
Other - Usual Route
In Case of Emergency Notify
(obtain release with signature)
Name
First Last
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship:
Military History
Have you served?*
- Yes
- No
What type of discharge did you receive?
Enlistment Date:
Discharge Date:
Were you involved in armed conflict?
- Yes
- No
What branch of service were you in?
Where:

Resident Application Form

Step 1 of 4

Referral Information

Demographic Information

Family

Demographic Information Continued

Legal History

Criminal History

Psychiatric History

Medications

Substance Use Information

Substance Use Information (cont.)

In Case of Emergency Notify

Military History

Medical History

Financial Information

Parenting Information

Please complete the following if applicable

Statement of Applicant