Legal Name
*
First Name
Last Name
Preferred Name (if different)
First Name
Last Name
Email
Phone
(###)
###
####
Date of Birth
*
MM
DD
YYYY
Gender at birth
*
Female
Male
What are your goals in a long term care setting?
How did you hear about us?
Web Search
Case Manager
Atlas Free Referral
A friend
Other facility
Are you a United States citizen?
*
YES
NO
Do you have any pre-existing medical or mental conditions? If yes, please specify:
*
Do you have a history of self-harm, or have you ever attempted suicide? If yes, when was the last time? (We will evaluate serious mental illnesses/SMI on a case-by-case basis).
*
Have you ever been hospitalized for any reason? If yes, please explain.
Do you have a history of alcohol or drug use? If yes, please list the drug(s) and the last day of use for alcohol and/or drugs.
*
Are you currently taking any medications? If yes, please list the name(s), dosage, and reason/diagnosis.
*
If you are currently taking any perscription based on a medical or mental health diagnosis, do you understand and agree to our requirement that you must continue your prescribed course of treatment and medication while in our program?
*
Yes
No
Do you understand and agree, that once you have entered our residential program you will be seen by trusted external healthcare and mental health providers, and if diagnosed you will be required to follow any prescribed course of treatment, including but not limited to counseling, prescribed medications, etc. in order to continue in our program?
*
Yes
No
Do you have any allergies or dietary restrictions?
*
Any allergies to animals like horses, dogs or other animals that you might encounter as a part of therapeutic services, like Equine or Canine therapies?
Are you currently pregnant?
*
Do you currently have custody or guardianship of any persons under 18?
*
Do you have any children in foster care or living with family or friends? If yes, please list number of children, their name(s), age(s), name(s) of who has custody, and their telephone number(s).
Have you ever been arrested? If yes, what were the charges and in what state(s) were you charged? (This doesn't affect your eligibility for the program. It helps us know what we may be able to assist with legally).
*
Do you currently have a case worker or probation officer assigned to you? If yes, please list their name(s), case number(s), and telephone number(s).
*
Have you previously received support or services from any organizations or facilities, or have been enrolled in a short or long term shelter program? If yes, please provide the program/facility name, duration, and a summary of your experience.
If applicable, what types of support or services were most beneficial to you in the past?
Do you feel that you could be in danger? If yes, from whom? Does this person(s) know where you are?
*
At what age were you first sexually exploited?
Are you willing to not have access to your personal cell phone for the first two phases of our program? (Typically 6-13 months). Residents will be allowed to use a facility phone once per day after 5pm, for a 15 minute phone call to approved family or friends.
*
Are you willing to share a room with another resident?
*
Are you okay with being in a faith-based program where participation in faith-based activities is not mandatory, but due to safety issues, your attendance is.
*
Please provide any additional information that you think will help us; such as, special requests or needs, or any other information.
