We are here to help you! Call us:
(214) 272-7322
Struggling? You’re Not Alone. Get Support Anytime, 24/7
Patient Intake
We are here to help you! Call us:
(214) 272-7322
Patient Intake
We are here to help you! Call us:
(214) 272-7322
Patient Intake
Home
Services
Intensive Outpatient Substance Abuse Treatment
Medication-Assisted Treatment (MAT)
Mental Health Counseling
DUI/DWI and Court-Mandated Services
Family and Couple Services
Relapse Prevention & Aftercare
Peer Support and Recovery Coaching
Community Outreach & Education
Supportive Subsidized Transitional Housing
Patient Intake
About Us
Insurance & Payment Options
Home
Services
Intensive Outpatient Substance Abuse Treatment
Medication-Assisted Treatment (MAT)
Mental Health Counseling
DUI/DWI and Court-Mandated Services
Family and Couple Services
Relapse Prevention & Aftercare
Peer Support and Recovery Coaching
Community Outreach & Education
Supportive Subsidized Transitional Housing
Patient Intake
About Us
Insurance & Payment Options
Exclusively At Our Clinic
Life & Career Mental Health Burnout
Sports Enhancement Therapy (SPET)
Family Goal Setting Augmentation
Navigating the Transition to Adulthood (A Holistic Mental Health Services)
Helicopter Parenting Intervention Services
Life Purpose Mental Optimization Services
Mental Health Performance Optimization Services
Step-Parenting Counselling
Co-Parenting Optimization
Grievance Counseling
Transitional Housing Program
Housing Intake Form
Veterans Program
Exclusively At Our Clinic
Life & Career Mental Health Burnout
Sports Enhancement Therapy (SPET)
Family Goal Setting Augmentation
Navigating the Transition to Adulthood (A Holistic Mental Health Services)
Helicopter Parenting Intervention Services
Life Purpose Mental Optimization Services
Mental Health Performance Optimization Services
Step-Parenting Counselling
Co-Parenting Optimization
Grievance Counseling
Transitional Housing Program
Housing Intake Form
Veterans Program
Home
About Us
Services
Intensive Outpatient Substance Abuse Treatment
Medication-Assisted Treatment (MAT)
Mental Health Counseling
DUI/DWI and Court-Mandated Services
Family and Couple Services
Relapse Prevention & Aftercare
Peer Support and Recovery Coaching
Community Outreach & Education
Supportive Subsidized Transitional Housing
Patient Intake Form
Grievance Counseling
Step-Parenting Counselling
Co-Parenting Optimization
Insurance & Payment Options
Exclusively At Our Clinic
Life & Career Mental Health Burnout
Sports Enhancement Therapy (SPET)
Family Goal Setting Augmentation
Navigating the Transition to Adulthood (A Holistic Mental Health Services)
Helicopter Parenting Intervention Services
Life Purpose Mental Optimization Services
Mental Health Performance Optimization Services
Transitional Housing Program
Housing Intake Form
Veterans Program
Contacts Us
Home
About Us
Services
Intensive Outpatient Substance Abuse Treatment
Medication-Assisted Treatment (MAT)
Mental Health Counseling
DUI/DWI and Court-Mandated Services
Family and Couple Services
Relapse Prevention & Aftercare
Peer Support and Recovery Coaching
Community Outreach & Education
Supportive Subsidized Transitional Housing
Patient Intake Form
Grievance Counseling
Step-Parenting Counselling
Co-Parenting Optimization
Insurance & Payment Options
Exclusively At Our Clinic
Life & Career Mental Health Burnout
Sports Enhancement Therapy (SPET)
Family Goal Setting Augmentation
Navigating the Transition to Adulthood (A Holistic Mental Health Services)
Helicopter Parenting Intervention Services
Life Purpose Mental Optimization Services
Mental Health Performance Optimization Services
Transitional Housing Program
Housing Intake Form
Veterans Program
Contacts Us
Home
About Us
Services
Intensive Outpatient Substance Abuse Treatment
Medication-Assisted Treatment (MAT)
Mental Health Counseling
DUI/DWI and Court-Mandated Services
Family and Couple Services
Relapse Prevention & Aftercare
Peer Support and Recovery Coaching
Community Outreach & Education
Supportive Subsidized Transitional Housing
Patient Intake Form
Grievance Counseling
Step-Parenting Counselling
Co-Parenting Optimization
Insurance & Payment Options
Exclusively At Our Clinic
Life & Career Mental Health Burnout
Sports Enhancement Therapy (SPET)
Family Goal Setting Augmentation
Navigating the Transition to Adulthood (A Holistic Mental Health Services)
Helicopter Parenting Intervention Services
Life Purpose Mental Optimization Services
Mental Health Performance Optimization Services
Transitional Housing Program
Housing Intake Form
Veterans Program
Contacts Us
Welcome!
Please complete this form to the best of your ability. All information will remain confidential and is used only to determine eligibility and support your success in our transitional housing program.
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Personal Information
Full Name:
Date of Birth
Gender
Select Gender
Male
Female
Non-Binary
Prefer not to say
Phone Number
Email Address
Social Security Number (Last 4 Digits):
Preferred Languagee:
Race/Ethnicity (Optional):
Current Living Situation
Where are you currently staying?
Homeless (on the street)
Emergency shelter
Couch surfing
Jail/Prison (enter release date below)
Transitional housing
Other
Please describe
If currently incarcerated, what is your expected release date?
Are you fleeing domestic violence?
Yes
No
Do you have a history of eviction?
Yes
No
Emergency Contact
Full Name of Emergency Contact:
Relationship to You:
Phone Number:
Alternate Phone Number (Optional):
Other: any of
Employment & Income
Are you currently employed?
Yes
No
Employer Name:
Position:
Hours per Week:
Monthly Income (Approximate):
Do you have any other sources of income?
SSI/SSDI
Unemployment
Family Support
Other (please describe)
None
Would you like help finding a job?
Yes
No
Health & Wellness
Do you have any current medical conditions?
Yes
No
Please list:
Are you currently taking any medications?
Yes
No
Please list:
Do you have a mental health diagnosis?
Yes
No
Do you require ongoing medical care?
Yes
No
Have you ever used drugs or alcohol?
Yes
No
Last use (if applicable)
Are you enrolled in outpatient treatment?
Yes
No
Goals & Services Needed
What are your goals while in transitional housing?
Find permanent housing
Get a job
Maintain sobriety
Reunite with family
Manage mental health
Build financial stability
Other
Other:
Do you need help with any of the following documents/services?
State ID
Social Security Card
Birth Certificate
Food Assistance
Health Insurance
Transportation
None of the above
Who Referred you to us:
Agreement
Abc
*
Acknowledgment I understand that transitional housing requires participation in program activities, following community rules, and working toward housing and employment goals. I certify that the information I’ve provided is accurate to the best of my knowledge
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