Hope's Bridge Resident Profile
Please complete this confidential profile to determine eligibility and develop your individualized recovery plan.
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PERSONAL INFORMATION
Date of Submission *
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Full Name *
Date of Birth *
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Age *
Social Security Number *
Email *
Phone Number *
Preferred Contact Method *
Required
Referred by (if no one, type "self"): *
Gender *
Race *
Ethnicity *
Sexual Orientation
Are you currently experiencing homelessness or unstable housing? *
Previous Address *
Preferred Date of Entry *
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Veteran Status *
Financial Status *
Currently Employed *
Average Monthly Household Income *
Do you have health insurance? *
RECOVERY AND HEALTH INFORMATION
Are you currently detoxing? *
If you are currently detoxing, please list the substance(s).
What substances have you used in the last 72 hours? *
Substance Use History
(For each substance, list age of first use, date of last use, and daily amount used.)
Have you received Naloxone/Narcan to reverse an overdose? *
If yes, how many times have you received Naloxone/Narcan?
Have you been to treatment before (inpatient, outpatient, or residential)? List provider and date(s): *
Do you have any ongoing health conditions (e.g., Hepatitis C, HIV, diabetes)? If yes, please describe:
Do you have a history of seizures? *
Allergies or Medical Alerts *
Would you like to be tested for STDs or other communicable diseases? *
Co-Occurring Mental Health Diagnoses *
List Co-Occurring Mental Health Diagnoses (if applicable)
Are you currently prescribed medication for a mental health or medical condition? *
List medications if applicable
Emergency Room visits in the past 90 days? *
In your own words, why are you seeking recovery services at Hope's Bridge? *
LEGAL INFORMATION
Have you ever been arrested? *
If yes, how many times have you been arrested? *
Have you been convicted of any criminal offenses?
Clear selection
If yes, list type (misdemeanor/felony), charges, and dates: *
Do you currently have pending legal charges? *
Have you ever been convicted of a sexual offense? *
Are you currently on probation or parole? *
Have you been administered court-ordered treatment before? *
EDUCATION AND VOCATION
Highest level of education completed *
Are you currently enrolled in school or training? *
Are you participating in vocational or skills training? *
Current or most recent occupation *
RECOVERY PATHWAY
Primary Recovery Pathway (select all that apply) *
Required
Are you a survivor of domestic violence? *
FAMILY AND SOCIAL INFORMATION
Marital Status *
Do you have children? *
Who referred you to Hope's Bridge? *
Do you have family or social support for your recovery? *
EMERGENCY CONTACTS
Primary Emergency Contact Name *
Primary Emergency Contact Phone Number *
Primary Emergency Contact Address *
Primary Emergency Contact Relationship to you *
Secondary Emergency Contact Name
Secondary Emergency Contact Phone Number
Secondary Emergency Contact Address
Secondary Emergency Contact Relationship to you
LEGAL/COURT CONTACTS (if applicable)
Probation/Parole Officer
(List name, Jurisdiction, Phone Number)
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