The Rose Home Application

Name____________________________________  Date ___________________ DOB______________

Most recent address_______________________________________________________________
                                    Street                                                               City __________________   		 State______		 Zip Code____________

Current phone ___________________

Age ___________       SSN ____________________________

Place of birth _______________________________________ 

Referral source _____________________________________ Race ___________________________

Marital status ______________________________________ Religion ________________________

Height ___________ Weight _____________ Eye color _______________  Hair color ___________

Children? _______________ Residing where? _____________ Custody status? _______________ 

Veteran __________ Branch of Service ____________________ Discharge date ________________

Income source ______________________________________    Amount ________________________

Frequency _______________________________

Do you have Any Convictions? ______________________________________________________________

Legal status:  ____ Probation _____Parole _____ Community Corrections ____Warrants

_____Re-Entry_____Diversion Program _____ Home Detention _____ Drug Court _____ Pending Cases 
			
Discharge/Release Date (from rehab, jail, prison)                                              

History of Substance Abuse 		Sobriety Date:  _________________
When did you start using and what did you use?  ____________________________________________________________________________________________________________________________________________________________________________________

What are your drug(s) of choice?  ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Are you convinced that you are an alcoholic or addict?  Why? 

_____________________________________________________________________________________

_____________________________________________________________________________________

Previous Treatment (Where/How Long?) _________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Previous stays at other half-way houses, treatment centers or recovery homes.  When? 
_____________________________________________________________________________________

_____________________________________________________________________________________

What makes this attempt in different?____________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Family Physician –
Name ___________________________________________Phone _______________________________

Address ______________________________________________________________________________
Medical or mental conditions: (i.e.  allergies, depression or other)				
_______________________________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Are you pregnant? ______________________________________________________________________
Current medications and reason prescribed: ___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Emergency Contact – Name _______________________________________________________

                    Address _____________________________________________________

                    Phone # _____________________________________________________

													
Page 3

Any trade/job skills? _________________________________________________________________

What do you expect to gain from your stay at The Rose Home?
___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

In what areas do you need the most help?  (Please answer Yes or No)
Gaining a better understanding of you:_________
Getting rid of or dealing with anger:_____________
Becoming more assertive:_________
Depression:___________
Self Respect:________
Understanding Feelings of Guilt, Loneliness, Loss or Separation: _______
Tolerance/Acceptance:_________
Gaining a Positive Attitude:________
Strengthening or clarifying your religious beliefs: _________
Maintaining abstinence: ___________
Social Skills: __________
Education or Job Skills: ___________
Family Matters: __________
Legal assistance: ________
Physical assistance:_________

Page 4

Please write a short Story of you and why you want to come to The Rose Home
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Signature__________________________________ Date____________________