Omega Recovery Application

Resident Information

Omega Recovery Application Form

Residents Information

Full Name
Phone Number
Address
Gender
Date of Birth
Email
Social Security Number

Sponsor Information

Financial Sponsor Information

(If other than resident)

Full Name
Agency/ Organization Name (If Applicable)
Phone Number
Address
Home Phone
Cell Phone
Work Phone
Email
Social Security Number

Family Information

Fathers Information

Full Name
Please Check
Address
Phone
Email
Stepmother / Significant Other’s Full Name (If Applicable)

Mothers Information

Full Name
Please Check
Address
Phone
Email
Stepfather / Significant Other’s Full Name (If Applicable)

Referral Information

Referral Source Information

How did you first come to find out about Omega Recovery?
If you found Omega Recovery on the internet, please list key words/phrases that you used to find us:

Please tell us of any specific person who referred you to us (i.e. psychologist, educational consultant, psychiatrist, therapist, alumnus, school counselor, family friend, etc.)

Do we have your permission to contact this person.
Name of Referral Source:
Their Relationship to you:
Referrer's Address
Phone
Email

Professional Information

Professional Involvements

Please list all mental health professionals and treatment programs that have been involved with the resident over the last 2 years.

Professional Service

Full Name
Updates
Dates of Service
Program Name (if applicable)
Type of Services:
Address
Business Phone Number
Cell Phone (if applicable)
Email

Professional Service

Full Name
Updates
Type of Services:
Dates of Service
Program Name (if applicable)
Address
Business Phone Number
Cell Phone (if applicable)
Email

Professional Service

Full Name
Updates
Type of Services:
Dates of Service
Program Name (if applicable)
Address
Business Phone Number
Cell Phone (if applicable)
Email

Medical History

Significant Medical History

General Health Condition
Does the applicant have any food restrictions?
If yes, please explain:
Allergies
List/Explain any Chronic conditions (asthma, heart murmur, diabetes, enuresis)
History of surgeries/broken bones
Has applicant ever been hospitalized other than for above described surgeries or fractures? If so, why and for how long?

Addiction Information

Addiction

Please tell us applicant’s addiction: (drug of choice, alcohol use, length of time using)

Medications

Please list the following:
Name of Medication
Date Prescribed
Dosage/Schedule
Reason for Medication

Emotional/Mental Health Inventory

Has the applicant been given a diagnosis by a qualified mental health professional:
If Yes, please list the following below: Diagnosis, Date Given, Name of Professional
Please check any of the following that apply to the resident:
 
For any of the items that are marked “Yes”, please provide explanation:

Other Information

Other Information

Current Academic Status
What is the participant’s current grade level?
If the applicant has not completed high school, how many credits are needed for graduation?
Please describe any college experience held by the applicant:
Please explain any know learning differences for the applicant.

Vocational/Employment Interests

Describe any particular vocational interests or skills that the applicant has:
Has the applicant ever been gainfully employed? If so, please describe:

Additional Comments

Is there anything else we should know about the applicant?
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