Skip to content
HOME
Programs
Long Term
Veterans
Transitional Housing
Short Term
About Us
Mission
Staff
Departments
History
Learn More
Apply
FAQ
Community Partners
Downloads&Articles
Outreach
Donate
Donate Thank You
Volunteer
Store
HOME
Programs
Long Term
Veterans
Transitional Housing
Short Term
About Us
Mission
Staff
Departments
History
Learn More
Apply
FAQ
Community Partners
Downloads&Articles
Outreach
Donate
Donate Thank You
Volunteer
Store
Apply
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Name
*
First
Middle
Last
Age
*
Program Applying for:
*
Longterm
Shortterm
Veterans
If Short-term, how many days?
*
Phone Number
Email
Do you have a Social Security Number?
*
Yes
No
Do you have a copy of your Social Security Card?
*
Yes
No
SSN
*
Gender
*
Male
Female
Are you Pregnant?
*
Yes
No
Date of Birth
*
Birth City
*
Birth State
*
County
*
Distinguishing Marks (tattoos, scars)
Height
*
Weight
*
Hair Color
*
Eye Color
*
Relationship Status
*
Married/Co-Habitating
Divorced
Single/Never Married
Spouse or Significant other’s name
*
1st Divorce Date
*
2nd Divorce Date
3rd Divorce Date
1st Divorce County
*
2nd Divorce County
3rd Divorce County
1st Divorce State
*
2nd Divorce State
3rd Divorce State
Do you maintain a primary residence?
*
Yes
No
Are you homeless?
*
Yes
No
How long have you been homeless?
*
Do you have Children?
*
Yes
No
How Many Children do you have?
*
Father
*
Living
Deceased
Father's Name
*
First
Last
Mother
*
Living
Deceased
Mother's Name
*
First
Last
In case of Emergency notify:
*
Phone Number of Emergency Contact
*
Relationship
*
Referred By
*
Have you ever Applied to First Inc before?
*
Yes
No
Were you accepted?
*
Yes
No
Please list the Date(s) & Month(s) completed
*
Do you have a current valid Driver’s License?
*
Yes
No
What is the driver’s license number and state issued
*
Have you ever had a driver's liscense?
*
Yes
No
Please list any outstanding tickets, fines, etc. with the county and state where the infractions took place:
Have you ever served in the Military?
*
Yes
No
Branch of service
*
Eligible for benefits?
*
Yes
No
Unknown
Service Number
Number of Grant Per-diems previously used
*
Type of Discharge
*
Year Discharged
*
Have you ever been convicted of a crime?
Yes
No
Have you ever commited or been charged with:(choose all that apply)
*
Child Abuse/Neglect
Arson
Sexual Offense
Assault or Domestic Violence
No
Have you ever been convicted of:(choose all that apply)
*
Child Abuse/Neglect
Arson
Sexual Offense
Assault or Domestic Violence
No
Explain Child Abuse/Neglect
*
Explain Arson
*
Explain Sexual Offense
*
Explain Assault or Domestic Voilence
*
Offense
*
Offense2
Offense3
Offense4
Offense5
Offense6
Disposition
*
Disposition
Disposition
Disposition
Disposition
Disposition
Date
*
Date
Date
Date
Date
Date
Are you currently on Probation or Parole?
*
Yes
No
Probation/Parole Officer's Name
*
Probation County
*
Do you have any pending legal actions?
*
Yes
No
What is your current offense and status?
*
Please list pending legal action(s) by name and date
*
Do you have any pending warrants?
*
Yes
No
City
*
State
*
Attorney's Name
First
Last
County
*
Judge
Warrant for:
*
Warrant for:
City
*
City
State
*
State
Have you ever been Employed?
*
Yes
No
Are you currently Employed?
*
Yes
No
Current Employers Name
*
Previous Employer's Name
*
Last/Current From Date
*
Last/Current to Date
*
Reason no longer there?
*
Do you have any outstanding debts?
*
Yes
No
Outstanding debts (child support, installment loans, IRS, etc.)
*
Arrangements for Payments, Explain?
*
Are you ordered to pay Child Support?
*
Yes
No
Are you behind on Child Support?
*
Yes
No
How far behind are you?
*
Do you receive any ongoing financial reimbursement for any reason? (Such as disability ,trust funds ,annuities etc.)?
*
Yes
No
Explain reimbursements
*
Are you currently applying for disability (SSI, SSDI)?
Yes
No
For what reason are you appling for disability?
*
Drug of choice
*
Age of first use
*
At most daily
*
Date of last use?
*
2nd Drug of choice
Age of first use
At most daily
Date of last use?
3rd Drug of choice
Age of first use
At most daily
Date of last use?
4th Drug of choice
Age of first use
At most daily
Date of last use?
5th Drug of choice
Age of first use
At most daily
Date of last use?
6th Drug of choice
Age of first use
At most daily
Date of last use?
7th Drug of choice
Age of first use
At most daily
Date of last use?
8th Drug of choice
Age of first use
At most daily
Date of last use?
Prior drug treatment programs and dates completed
Do you have knowledge of 12 step programs?
*
Yes
No
Have you ever participated in 12 Step Fellowships?
*
Yes
No
High School Graduate?
*
Yes
No
Any College Classes?
*
Yes
No
GED obtained?
*
Yes
No
College Degree?
*
Yes
No
Last School grade completed
*
Degrees earned (choose all that apply)
*
AAS
Bachelors
Masters
Doctorate
Do you have any difficulty reading?
*
Yes
No
Do you have any difficulty writing?
*
Yes
No
Do you have any Vocational or Occupational Education?
*
Yes
No
Describe/List Vocational or Occupational Skills
*
Describe/List any special areas of study
Are you on Medicaid?
*
Yes
No
Do you have Insurance?
*
Yes
No
Please list your Insurance information
*
Do you have Dental problems?
*
Yes
No
Describe your Dental problems?
*
Are you currently on any medications? (Prescribed or Over-the-counter)
*
Yes
No
Medication 1
*
Medication 5
Medication 9
Medication 13
Medication 17
Medication 2
Medication 6
Medication 10
Medication 14
Medication 18
Medication 3
Medication 7
Medication 11
Medication 15
Medication 19
Medication 4
Medication 8
Medication 12
Medication 16
Medication 20
Who is paying and/or providing for your medications?
*
Are you currently under the care of a physician?
*
Yes
No
Physician's contact information
*
Reason for Physician's Care?
*
Have you been tested for Tuberculosis(TB) in the past year?
*
Yes
No
Tuberculosis(TB) test result
*
Positive
Negative
When is the last time you have had unprotected sex?
*
Have you ever been tested for HIV/AIDS, STDs, HEP A,B,C,D,E? (choose all that apply)
*
HIV Aids
STD’s
Hep A,B,C,D,E
None
Result of HIV/Aids test
*
Type of and Result of STD test
*
Type of and result of HEP test
*
List any Medical Problems?
Have you ever been hospitalized for any illnesses?
*
Yes
No
hospital(s) and date(s)
*
Do you have any known Allergies?
*
Yes
No
What Allergies do you have?
*
Penicillin or Sulfa
Asprin, Codeine, Morphine
Mycins or other Antibiotics
Merthiolate, Mecurochrome
Other Drugs?
Nail Polish or Cosmetics
Adhesive Tape
Any Food?
Other Allergies?
List other Drug Allergies
*
List Food Allergies
*
List Other Allergies
*
Do you have a history of: (Check all that apply)
*
Asthima
TB
Diabetes
Hepatitus
Heart Disease
Epilepsy
Seizures
None
Seizure caused by and when
*
Have you had any of the following injuries? (choose all that apply)
*
None
Concussions or Head injuries
Sprains
Dislocations
Lacerations
Broken or Cracked Bones
Concussions/head injuries When?
*
Sprains When?
*
Dislocations When?
*
Lacerations When?
*
Broken/cracked bones When?
*
SURGERIES: Have you had any of the following surgeries:(Choose all that apply)
*
Tonsillectomy
Appendectomy
Other Surgeries
No
Other Surgery Type and Year
*
Other Surgery Type and Year
Other Surgery Type and Year
Other Surgery Type and Year
Other Surgery Type and Year
Other Surgery Type and Year
If you have ever been advised to have any surgical operation which has not been done?
*
Yes
No
Please provide details
*
Have you ever been hospitalized and/or treated for any mental health issues?
*
Yes
No
Voluntary or Involuntary?
*
Voluntary
Involuntary
Hospital(s) and Date(s)
*
Reason/Diagnosis
*
Have you ever been given a mental health diagnosis?
*
Yes
No
Please list your specific diagnosis(es)
*
Have you ever heard voices?
*
Yes
No
When did you hear voices?
*
What was the Outcome?
*
Have you ever had visual hallucinations?
*
Yes
No
When did you have visual hallucinations
*
What was the Outcome?
*
Have you ever beed sexually assaulted?
*
Yes
No
Date(s) of sexual assault?
*
Have you ever received counseling for the sexual assault(s)?
*
Yes
No
Are you currently Suicidal?
*
Yes
No
Have you ever tried to commit Suicide?
*
Yes
No
List the date(s) of attempt(s)
*
Have you ever exhibited any self-harm behaviors such as cutting, bulimia, etc?
*
Yes
No
Please explain self-harm behavior(s)
*
Have you ever overdosed?
*
Yes
No
How many times?
*
Circumstances surrounding overdose (when, where, why, how):
*
Have you ever been a victim of a violent crime?
*
Yes
No
Please explain the violent crime:
*
Do you currently have a mental health provider?
*
Yes
No
Please list current provider(s):
*
Have you recieved counseling in the past?
*
Yes
No
Please list past provider(s):
*
On a scale of 1 to 10, how serious is your problem with drugs and alcohol? (Choose one)
*
1
2
3
4
5
6
7
8
9
10
On a scale of 1 to 10, how motivated are you to make positive changes in your life? (Choose one)
*
1
2
3
4
5
6
7
8
9
10
Autobiography
*
Name
*
First
Middle
Last
Name
*
First
Middle
Last
I,_(Type name below)_authorize the following:
*
First
Middle
Last
Witness Name
*
I,_(Type name below)_authorize the following:
*
First
Middle
Last
I,_(Type name below)_acknowledge and agree to each of the following:
*
First
Middle
Last
Witness Name
*
Submit
