Get Nh Nchc Client Application For Admission To Friendship House 2020-2025

Filling out the NH NCHC Client Application for Admission to Friendship House can be a straightforward process when approached step by step. This guide is designed to support you in completing the application efficiently and accurately.

Follow the steps to successfully complete the application.

1. Click the ‘Get Form’ button to access the application form and open it in your editor.
2. Begin by filling in the 'Date' field with the current date. Then indicate whether you were referred by someone such as a provider, emergency room, parole officer, or attorney by selecting 'Yes' or 'No'. If applicable, specify the name of the individual who referred you.
3. Complete the 'Personal Information' section by providing your name, date of birth, gender identity, marital status, phone number, social security number, mailing address, and email. If you have a residential address different from the mailing address, include that as well. Indicate if you are homeless.
4. If applicable, provide the name and contact information of a guardian or representative payee. Fill in your preferred drugs, age of first use, frequency and quantity of alcohol consumption, and any history of seizures with withdrawal from alcohol.
5. Indicate whether you have medical insurance and, if yes, provide the name of the insurance company, group number, and member number. State whether you currently have an income and, if so, include the approximate earnings and employer name.
6. Address any disabilities or children you may have and mention if the Department of Children, Youth and Families (DCYF) is involved. Proceed to the 'Legal Information' section, where you will state any current legal charges, warrants, or history regarding treatment mandates.
7. In the 'Health Information' section, indicate whether you have a primary care provider or a behavioral health provider. Detail any major medical or mental health concerns, including relevant diagnoses or disorders.
8. Provide information about any communicable diseases you may have, list any allergies or dietary restrictions, and mention how often you've visited the emergency room in the past six months. Share your goals for treatment.
9. Confirm if you have proof of New Hampshire residency, and list any current medications you are taking. Ensure all precursors for your application, including a signed medication list, are prepared.
10. Once all sections are complete, review the document for accuracy. Save your changes, and you may choose to download, print, or share the form as necessary.

Complete the NH NCHC Client Application For Admission To Friendship House online today!