Get Ca Henry Ohlhoff House Working Mens Residential Program Intake Application 2019-2025

Completing the CA Henry Ohlhoff House Working Mens Residential Program Intake Application online is a straightforward process that ensures your information is collected accurately to facilitate your admission into the program. This guide will walk you through each step to ensure you feel supported and confident while filling out the application.

Follow the steps to complete your online application.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Begin filling out the personal information section. Provide your full name, date of birth, phone number, email address, and home address. Make sure to fill in all required fields accurately.
3. Indicate if we may contact you at all of the provided contact information by selecting 'Yes' or 'No'. Fill out your marital status, sexual orientation, race (optional), and ethnicity (optional).
4. Select the program you are interested in (90-Day or 6 Month) and mention how you learned about the Henry Ohlhoff House.
5. In the employment information section, specify if you are employed. If yes, provide your occupation, employer, duration of employment, and salary. If not employed, list your last employment or current source of income.
6. Fill out the substance use and treatment history for all substances used in the past 12 months. Clearly indicate the frequency and amount of use, as well as detailing your primary substance and any prior treatment programs attended.
7. Complete the medical information section by listing current medical conditions, allergies, and information about any mental health services you may be receiving.
8. Provide health insurance information, ensuring to include the insurance company, identification number, and relevant phone numbers.
9. Complete the legal information section by noting any pending court cases and if you are on probation or parole. Provide requested details for your probation officer.
10. Complete the financial assessment by indicating your ability to meet initial payment and weekly fee requirements. Add any comments if necessary.
11. Fill out emergency contact details, including names, relationships to you, and phone numbers.
12. Lastly, read and sign the certification statement, ensuring that all provided information is accurate and that you understand the sobriety requirements. Include your signature and the date.
13. After completing the form, review all entries for accuracy. Save changes, and choose to download, print, or share the form as needed.

Complete your application online today to take the next step toward recovery.