Her Story Application
Please fill out the information requested below and we will get back to you within 24 hrs.
Email address *
Your Name *
Is this application for: *
Client's Name *
If you are applying on behalf of someone else, please explain your relationship and whether or not she is willing to get help.
Birthdate *
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Zip Code *
Ethnicity *
Phone number *
Are you currently employed? If yes, where at? *
What is your current living situation (homeless, with friends, etc.)? *
What substances are you currently using (heroin, cocaine, etc.)? *
When was the last time you used? *
List past treatment or recovery programs, if any. *
Do you currently have a sponsor? *
Do you have any Court, Probation or Children's Services cases that are currently open? If yes, what county are your services in? *
Do you have any past or current mental health diagnosis? If yes, please provide your diagnosis. *
Do you have insurance, if yes, please include your provider: *
Do you have any history of Suicidal Ideations? *If you are currently experiencing a mental health crisis, please call 911 or go to your nearest Emergency Room. *
Are you currently experiencing any of the following symptoms? *
Required
Are you currently on any medications? If yes, please list them. *
What do you hope to accomplish by coming to Her Story? *
How did you hear about us? *
Please share anything else you would like us to know.
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